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Xitirarp 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

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http://www.archive.org/details/physicaldiagnosi1912cabo 


Cabot — Physical  Diagnosis 


ARGYRIA 

Silver  Nitrate  Poisoning,  with  Slaty  Blue  Color  of  Skin 

{Painted  from  Life) 


PHYSICAL  DIAGNOSIS 


BY 

RICHARD  C.  CABOT,  M.  D. 

ASSISTANT    PROFESSOR   OF   MEDICINE   IN    HARVARD    UNIVERSITY 


jfiftb  JEOition 


REVISED  AND  ENLARGED,  WITH  5  PLATES 
AND  268  FIGURES  IN  THE  TEXT 


NEW  YORK 

WILLIAM   WOOD   AND   COMPANY 

MDCCCCXII 


'RC76 
C  1/ 

11(2. 


Copyright,  1912 
By  WILLIAM  WOOD  AND  COMPANY 


THE. MAPLE . PRESS. YORK. PA 


TO 

FREDERICK  C.  SHATTUCK,  M.  D. 

FORMERLY   JACKSON   PROFESSOR   OF   CLINICAL   MEDICINE 
IN  HARVARD  UNIVERSITY 

IN  EVIDENCE    OF   MY  APPRECIATION   OF 

THE    EXAMPLE    OF    SINCERITY,  COMMON   SENSE,  AND   ENTHUSIASM 

ESTABLISHED   BY   HIM   IN  THE   TEACHING  AND 

THE    PRACTICE    OF   MEDICINE 


PREFACE. 


This  book  endeavors  to  present  an  account  of  the  diagnostic 
methods  and  processes  needed  by  competent  practitioners  of  the 
present  date.  It  differs  from  other  books  on  the  subject  in  that  it 
makes  no  attempt  to  describe  technical  processes  with  which  the 
writer  has  no  personal  familiarity  and  gives  no  space  to  the  descrip- 
tion of  tests  which  he  believes  to  be  useless. 

To  gain  genuine  familiarity  with  all  the  technical  processes  de- 
scribed in  most  books  on  physical  diagnosis — such  familiarity  as 
makes  one  competent  to  use  them  with  due  regard  for  the  sources 
and  limits  of  error  inherent  in  them — ^needs  more  than  the  life-time 
of  one  man.  But  unless  one  has  one's  self  used  a  technical  process 
long  enough  to  gain  this  sort  of  mastery  over  it,  one  cannot  prop- 
erly describe  it,  far  less  recommend  it  to  others.  Because  of  my  lack 
of  personal  acquaintance  with  such  methods  as  cystoscopy,  ophthal- 
moscopy, and  laryngoscopy  I  have  attempted  no  description  of  them, 
although  I  believe  they  should  sooner  or  later  be  mastered  by  every 
internist.     All  that  I  have  described  I  know  by  prolonged  use. 

A  book  constructed  on  this  basis  should  make  obvious  what  its 
writer  considers  important  and  what  unimportant,  and  reveal  therein 
not  only  his  opinions  but  his  personal  Umitation?'.  But  I  believe 
there  is  no  longer  a  demand  for  books  that  attempt  impartially  to 
present  all  that  has  been  or  is  now  thought  of  value  by  some  one. 
The  personal  equation  cannot  and  should  not  be  ignored.  In  diag- 
nosis as  in  therapeutics  "What  do  you  find  valuable?"  is  the  question 
that  our  contemporaries  ask  of  any  one  of  us,  not  "What  has  been 
recommended?  " 

In  the  endeavor  further  to  break  down  the  false  distinction  be- 
tween clinical  diagnosis  and  laboratory  diagnosis  I  have  described 
all  the  methods  of  getting  at  an  organ — e.g.,  the  kidney — ^in  a  sin- 
gle section.  Palpation,  thermometry,  urinalysis  are  difTerent  proc- 
esses by  which  we  may  gather  information  about  the  kidney.  The 
student  should  be  accustomed  to  think  of  them  and  practise  them 
in  close  sequence. 

V 


vi  PREFACE 

For  the  same  reason  the  most  important  methods  of  investigat- 
ing the  stomach  have  been  grouped  together  without  any  distinction 
of  "clinical "  and  " laboratory "  procedure. 

For  the  illustrations  I  owe  many  thanks  to  many  persons,  espe- 
cially to  Drs.  Frank  Billings,  A.  E.  Boycott,  E.  H.  Bradford,  E.  R. 
Carson,  J.  Everett  Button,  R.  T.  Edes,  Joel  E.  Goldthwait,  J.  S. 
Haldane,  Frederick  T.  Lord,  R.  W.  Lovett,  H.  C.  Masland,  S.  J. 
Meltzer,  Percy  Musgrave,  R.  F.  O'Neil,  J.  E.  Schadle,  William  H. 
Smith,  W.  S.  Thayer,  and  G.  L.  Walton;  also  to  the  editors  of  The 
Bostoyi  Medical  and  Surgical  Journal,  The  St.  Paul  Medical  Journal, 
American  Medicine,  The  Journal  of  Experimental  Medicine,  and 
The  Lancet. 

My  assistant.  Dr.  Mary  W.  Rowley,  has  helped  me  very  much 
with  the  index  as  well  as  with  other  parts  of  the  book. 

190  Marlboro  St.,  Boston. 
June,  1905. 


TABLE  OF  CONTENTS. 


CHAPTER  I. 
DATA    RELATING    TO    THE    BODY    AS    A    WHOLE. 

Page 

1.  Weight,      i 

(a)    Causes  of  Gain  in  Weight,       i 

(6)    Causes  of  Loss  in  Weight,       i 

2.  Temperature — Technique    and  Sources  of  Error, 2 

(a)  Causes  of  Fever, 2 

(b)  Types  of  Fever, 2 

(c)  Subnormal  Temperature, 3 

(d)  Chills  and  Their  Causes, 3,  4 

CHAPTER  IL 
THE  HEAD,  FACE,  AND  NECK. 

I.   The  Cranial  Vault,       5 

1.  Size,  Shape, 5 

2.  Fontanels, 6 

3.  Hair, 6 

II.  The  Forehead, 7 

III.  The  Face  as  a  Whole, 8 

IV.  Movements  of  the  Head  and  Face, 13 

V.  The  Eyes, 14 

(a)  Ocular  Motion, 16 

(b)  The  Retina, , 17 

VI.  The  Nose, 17 

VII.  The  Lips, 19 

VIII.  The  Teeth, 21 

IX.  The  Breath, 22 

X.   The  Tongue, 22 

XI.  The  Gums, 24 

XII.  The  Buccal  Cavity,      . 25 

XIII.  The  Tonsils  and  Pharynx, 27 

XIV.  The  Neck, 29 


Glands, 29 

Abscess  or  Scars, 32 

Tumors  and  Cysts, 32 

Torticollis 33 

Vertebral  Tuberculosis, 34 

Bronchial  Cysts  and  Fistulas      34 

Actinomycosis, 35 

Cervical  Rib, 35 

Inflammatory  or  Dropsical  Swelling  of  Neck    ......  36 


viii  TABLE   OF  CONTENTS 

CHAPTER  III. 
THE  ARMS  AND  HANDS;  THE  BACK. 

Page 
The  Arms. 

I.  Paralysis,       37 

II.  Wasting  of  One  Arm, 39 

III.  Contractures, 39 

IV.  CEdema, 40 

V.  Tumors, 40 

VI.   Miscellaneous  Lesions  of  the  Forearm, 42 

The  Hands. 

I.   Evidence  of  Occupation, 43 

II.   Temperature  and  Moisture, 44 

III.  Movements,      ' 44 

IV.  Deformities, 51 

The   Xails 56 

The   BAck. 

I.   Stiff  Back, 57 

II.   Sacro-iliac  Disease, 57 

III.  Spinal  Curvature, 58 

IV.  Tumors  of  the  Back,       59 

V.  Prominent  Scapula, 59 

VI.  Spina  Bifida, 60 


CHAPTER  IV. 

THE  CHEST. 

TECHNIQUE  AND  GENERAL  DIAGNOSIS. 

Introduction. 

I.   Methods  of  Examining  the  Thoracic  Organs, 61 

II.    Regional  Anatomy  of  the  Chest, 61 

INSPECTION. 

I.    Size, 64 

II.   Shape, 64 

(a)  The  Rachitic  Chest, 65 

(b)  The  Paralytic  Chest, ,  .  65 

(c)  The  Barrel  Chest, 66 

III.   Deformities, 67 

(a)    Curvature  of  the  Spine, 67 

(6)   Flattening  of  One  Side  of  the  Chest, 68 

(c)  Prominence  of  One  Side  of  the  Chest 69 

(d)  Local  Prominences,       69 


TABLE    OF   CONTENTS  ix 

Page 

IV.   Respiratory   Movements, 70 

(a)    Normal  Respiration, 70 

(6)    Anomalies  of  Expansion, 71 

1.  Diminished  Expansion, 71 

2.  Increased  Expansion, 72 

(c)     Dyspnoea, 72 

V.  The  Respiratory  Rhythm, 74 

(a)  Asthmatic  Breathing,       74 

(b)  Cheyne-Stokes  Breathing, 75 

(c)  Restrained  Breathing, 76 

{d)    Stridulous  Breathing,       76 

VI.   Diaphragmatic  Movements    (Litten's  Phenomenon), 77 

VII.  The  Cardiac  Movements, 79 

1.  Normal  Cardiac  Impulse,      79 

2.  Displacement  of  the  Cardiac  Impulse, 82 

3.  Apex  Retraction, 83 

4.  Epigastric  Pulsation, 84 

5.  Uncovering  of  the  Heart 84 

VIII.  Aneurism  and  Other  Causes  of  Abnormal  Pulsations  of  the 

Chest  Wall, 85 

IX.   The  Peripheral  Vessels,       86 

(a)  Venous  Phenomena, 86 

(b)  Arterial  Phenomena, 88 

(c)  Capillary  Phenomena, 90 

X.   The  Skin  and  Mucous  Membranes,       90 

1.  Cyanosis, ' 90 

2.  (Edema, 91 

3.  Pallor, 92 

4.  Jaundice, 92 

5.  Scars  and  Eruptions 92 

XI.   Enlarged   Glands, 92 


CHAPTER   V. 
PALPATION  AND  STUDY  OF  THE  PULSE. 

I.  Palpation 94 

1.  The  Cardiac  Impulse, 94 

2.  Thrills, 95 

3.  Tactile  Fremitus, 96 

4.  Friction,  Pleural  or  Pericardial, 98 

5.  Palpable  Rales, 99 

6.  Tender  Points, 99 

II.  The  Pulse, 100 

1.  The  Rate, 10 1 

2.  Rhythm,       102 

3.  Compressibility,      102 


X  TABLE   OF   CONTENTS 

Page 

4.  Size  and  Shape  of  Pulse  Wave, 102 

5.  Tension, 103 

6.  Size  and  Position  of  Artery, 105 

7.  Condition  of  Artery  Walls, 106 

III.  Arterial  Pressure  and  the  Instruments  for  Measuring  it,    .  107 

1.  Systolic  or  Maximum  Pressure, 108 

2.  Diastolic  Pressure, no 

3 .  Normal  Readings, no 

4.  Use  of  Data, m 

CHAPTER  VI. 

ARTERIOGRAMS,  PHLEBOGRAMS  AND 
ELECTROCARDIOGRAMS. 

I.  Heart  Block,      113 

II.  Auricular  Fibrillation,      115 

III.  Paroxysmal  Tachycardia, 116 

IV.  Premature  Beats  (Extrasystoles), 118 

V.  Coupling  op  Heart  Beats  and  Alternation,     . 119 

CHAPTER  VII. 

.  PERCUSSION. 

I.  Technique, 120 

.  ,      f  Mediate  Percussion, 1 

1^  Immediate  Percussion, -.    .    .  J 

(b)  Auscultatory  Percussion, 126 

(c)  Palpatory  Percussion,       127 

II.  Percussion-Resonance  of  the  Normal  Chest, 128 

(a)  Vesicular  Resonance, 128 

(b)  Dulness  and  Flatness,       ■ 129 

(c)  Tympanitic  Resonance, 131 

(d)  Cracked-pot  Resonance,      134 

(e)  Amphoric  Resonance,      135 

(/)    The  Lung  Reflex, 135 

III.   Sense  op  Resistance, 136 

CHAPTER  VIII. 
AUSCULTATION. 

1.  Mediate  AND  Immediate  Auscultation, 137 

2.  Selection  of  a  Stethoscope, 138 

3.  The  Use  of  ihe  Stethoscope, 142 

A.  Selective  Attention  and  What  to  Disregard, 142 

B.  Muscle  Sounds, 145 

C.  Other  Sources  of  Error, 146 

4.  Auscultation  op  the  Lungs,      147 

I.   Respiratory  Types 148 

(a)    Vesicular  Breathing, 148 


TABLE   OF   CONTENTS  xi 

Page 

(6)    Tubular  Breathing, 150 

(c)  Broncho-vesicular  Breathing, 152 

(d)  Emphysematous  Breathing, 152 

(e)  Asthmatic  Breathing,      153 

(/)    Cog-wheel  Breathing,       153 

(g)    Amphoric  Breathing, 154 

(/i)    Metamorphosing  Breathing, 154 

II.    Differences  between  the  Right  and  the  Left  Chest, 154 

III.  Pathological  Modifications  of  Vesicular  Breathing,   .     .     ,     ...     .     .154 

(a)  Exaggerated  Vesicular  Breathing, 155 

(b)  Diminished  Vesicular  Breathing,       155 

IV.  Bronchial  Breathing  in  Disease, 157 

V.    Broncho-vesicular  Breathing  in  Disease, 157 

VI.   Amphoric  Breathing,       158 

VII.    Rales, .  158 

(a)  Moist, .  158 

(b)  Dry, •     •  i59 

(c)  Musical, 161 

VIII.   Cough.      Effects  on  Respiratory  Sounds, 161 

IX.  Pleural  Friction,       161 

X.   Auscultation  of  the  Voice  Sound, 163 

(a)  The  Whispered  Voice 163 

(b)  The  Spoken  Voice, 164 

(c)  Egophony, 164 

XI.   Phenomena  Peculiar  to  Pneumo-hydrothorax, 165 

(a)  Succussion, 165 

(b)  MetalHc  Tinkle, 165 

(c)  The  Lung  Fistula  Sound 166 

CHAPTER   IX. 
AUSCULTATION  OF  THE  HEART. 

1.  The  Valve  Areas, 167 

2.  Normal  Heart  Sounds, .  168 

3.  Modifications  in  the  Intensity  of  the  Heart  Sounds, 170 

(a)    Mitral  First  Sound,       170 

1.  Lengthening, 170 

2.  Shortening, 171 

3.  Doubling, 171 

(6)    The  Second  Sounds  at  the  Base  of  the  Heart, 171 

1.  Physiological  Variations,       171 

2.  Pathological  Variations, 174 

(a)   Accentuation  of  Pulmonic  Second  Sound, 174 

(6)    Weakening  of  Pulmonic  Second  Sound, 174 

(c)  Accentuation  of  the  Aortic  Second  Sound, 174 

(d)  Weakening  of  the  Aortic  Second  Sound, 174 

(c)    Modifications  in  Rhythm  of  Cardiac   Sounds  and   Doubling  of 

Second  Sounds, 175 


xii  TABLE   OF   CONTENTS 

Page 

(d)  Metallic  Quality  of  the   Heart  Sounds, 176 

(e)  "Muffled"  Heart  Sounds, 176 

4.   Sounds  Audible  Over  the  Peripheral  Vessels, 177 

CHAPTER  X. 

(Auscultation  of  the   Heart,   Continued.) 

CARDIAC  MURMURS. 

I.  Terminology, 178 

1.  Mode  of  Production,       178 

2.  Place  of  Murmurs  in  the  Cardiac  Cycle, 181 

3.  Area  of  Transmission, ...181 

4.  Intensity,  Quality,  and  Length,       183 

5.  Relation  to  Heart  Sounds, 184 

6.  Effects  of  Respiration,  Exertion,  and  Position. 185 

7.  Metamorphosis  of  Murmurs, 186 

II.  Functional  Murmurs, 186 

III.  Cardio-Respiratory  Murmurs, 188 

IV.  Venous  Murmurs, 189 

V.  Arterial  Murmurs, 189 

CHAPTER  XI. 

DISEASES  OF  THE  HEART. 

VALVULAR  LESIONS. 

1.  Valvular  and  Parietal  Disease, 191 

2.  The  Establishment  and  Failure  of  Compensation,       194 

3.  Hypertrophy  and  Dilatation, 196 

4.  Valvular  Disease, 201 

I.   Mitral  Regurgitation, 202 

(a)  Pre-compensatory  Stage, 203 

(b)  Stage  of  Compensation,       203 

(c)  Stage  of  Failing  Compensation, 207 

(d)  Differential  Diagnosis, 208 

II.    Mitral  Stenosis, 209 

1.  First  Stage, 212 

2.  Second  Stage, 213 

3.  Third  Stage, 214 

4.  Differential  Diagnosis, 215 

III.   Aortic   Regurgitation, 218 

1.  Inspection,      219 

(a)  Arterial  Jerking, 219 

(b)  Capillary  Pulsation, 220 

2.  Palpation, 221 

3.  Percus.sion, 222 


TABLE   OF  CONTENTS  XlU 

Page 

4.  Auscultation,      222 

5.  Summary  and  Differential  Diagnosis, 225 

6.  Prognosis, 225 

7.  Complications, 226 

IV.  Aortic  Stenosis, 227 

1.  (a)   The  Murmur,  .    .    .    .• 228 

(b)  The  Pulse, 229 

(c)  The  Thrill, 230 

2.  Differential  Diagnosis, 230 

V.   Tricuspid  Regurgitation, 232 

1.  (a)   The  Murmur, 233 

(b)  Venous  Pulsation, 234 

(c)  Cardiac  Dilatation, 235 

(d)  Feeble  Pulmonic  Second  Sound, 235 

2.  Differential  Diagnosis, 235 

VI.  Tricuspid  Stenosis, 237 

VII.  Pulmonary  Regurgitation, 237 

VIII.  Pulmonary  Stenosis, 238 

IX.  Combined  Valvular  Lesions, 239 

(a)  Double  Mitral  Disease, 240 

(b)  Aortic  and  Mitral  Regurgitation,       241 

(c)  Aortic  Stenosis  and  Regurgitation, 242 

CHAPTER  XII. 

PARIETAL  DISEASE  AND  CARDIAC  NEUROSES. 

I.  Parietal  Disease  of  the  Heart, 243 

1.  Acute  Myocarditis, 243 

2.  Chronic  Myocarditis, 244 

3.  Fatty  Overgrowth, 246 

4.  Fatty  Degeneration,       246 

II.   Disturbances   of   Rhythm, •    •    •  247 

1.  Tachycardia, 247 

2.  Bradycardia, 248 

3.  Arrhythmia, 248 

4.  Palpitation, 249 

III.   Congenital  Heart  Disease,      .    .    .    .  ■ 250 

CHAPTER  XIII. 

DISEASES  OF  THE  PERICARDIUM. 

I.  Pericarditis, 253 

(a)    Dry  or  Fibrinous,    ■ 253 

(&)    Pericardial  Effusion, 255 

1.  The  Area  of  Dulness,     .    ._ 256 

2.  The  Cardiac  Impulse  and  the  Pulse, 258 

3.  Pressure  Signs, 258 


xiv  TABLE   OF   CONTENTS 

Page 

(c)    Adherent  Pericardium, 260 

Retraction  of  Interspaces, 260 

Limitation  of  Respiratory  Movements,       260 

3.  Absence  of  Cardiac  Displacement  with  Change  of  Position,   .  260 

4.  Hypertrophy  and  Dilatation  not  Otherwise  Explained,      .     .  261 

5.  Capsular  Cirrhosis  of  the  Liver, 261 


CHAPTER  XIV. 

THORACIC  ANEURISM. 

Inspection  and  Palpation. 

(a)   Abnormal  Pulsation, 263 

(6)   Tumor, 264 

(c)  Thrill, 264 

(d)  Diastolic  Shock, 264 

{e)  Tracheal  Tug, 265 

(/)  Pressure  Signs,        266 

Percussion  Dulness, 267 

Auscultation, 267 

(a)  Murmurs, 267 

(b)  Diastolic  Shock  Sound, 267 

Radioscopy, 268 

Diagnosis, 269 


CHAPTER  XV. 
DISEASES  OF  THE  LUNGS  AND  PLEURA. 

BRONCHITIS,  PNEUMONIA,  TUBERCULOSIS. 

Tracheitis, 274 

Bronchitis, 274 

(a)  Physical  Signs, 274 

(b)  Differential  Diagnosis, 276 

Croupous  Pneumonia, 277 

(a)  Inspection, 278 

(b)  Palpation, 278 

(c)  Percussion, 278 

(d)  Auscultation, 279 

(e)  Differential  Diagnosis, 282 

Inhalation  Pneumonia, 283 

Broncho-Pneumonia,      283 

Pulmonary  Tuberculosis, 285 

(a)  Incipient  Tuberculosis, 285 

(b)  Moderately  Advanced  Cases, 288 

(c)  Advanced  Phthisis,      290 

(d)  Anomalous  Forms  of  Pulmonary  Tuberculosis, 294 


TABLE   OF  CONTENTS  XV 

CHAPTER  XVI. 

(Diseases  of  the  Lungs,  Continued.) 

Page 

1.  Emphysema, 296 

(a)  Small-Lunged  Emphysema, 296 

(b)  Large-Lunged  Emphysema, 296 

(c)  Emphysema  with  Bronchitis  and  Asthma,       299 

(d)  Interstitial  Emphysema, 299 

(e)  Complementary  Emphysema, 300 

(f)  Acute  Pulmonary    Tympanites, 300 

2.  Bronchial  Asthma, 300 

3.  Syphilis  of  the  Lung, .  301 

4.  Bronchiectasis, 302 

5.  Cirrhosis  of  the  Lung,      302 

6.  Examination  of  Sputa, 303 

(a)  Origin, 303 

(b)  Odor  and  Appearances, 303 

(c)  Staining, 305 

(d)  Microscopic  Examination, 305 

(e)  Description  of  Commoner  Organism 307 


CHAPTER  XVII. 

DISEASES  AFFECTING  THE  PLEURAL  CAVITY. 

I.   Hydrothorax, 308 

II.  Pneumothorax, 308 

III.  Pneumoserothorax  and  Pneumopyothorax, 310 

Differential  Diagnosis  of  Pneumothorax  and  Pneumohydrothorax,  .  312 

IV.  Pleurisy, 313 

1.  Dry  Pleurisy, 314 

2.  Pleuritic  Effusion,       315 

(a)  Percussion, 316 

(b)  Auscultation, 320 

(c)  Inspection  and  Palpation,       323 

3.  Pleural  Thickening, 325 

4.  Encapsulated  Pleural  Effusions,      326 

5.  Pulsating  Pleurisy  and  Empyema  Necessitatis, 327 

6.  Differential  Diagnosis  of  Pleural  Effusions, 327 

V.   Cyto-Diagnosis  of  Pleural  and  Other  Fluids, 330 

(a)   Technique, 330 

(6)    Interpretation  of  Results, 331 


TABLE   OF   CONTENTS 


CHAPTER  XVIII. 


ABSCESS,  GANGRENE,  AND  CANCER  OF  THE  LUNG,    PUL- 
MONARY ATELECTASIS,  CEDEMA,  AND  HYPOSTATIC 
CONGESTION. 

Page 

1.  Abscess  and  Gangrene  of  the  Lung, - 333 

2.  Cancer  of  the  Lung, 334 

3.  Atelectasis,      335 

4.  CEdema  and  Hypostatic  Congestion,       336 

CHAPTER  XIX. 

THE  ABDOMEN  IN  GENERAL,  THE  BELLY  WALLS,  PERI- 
TONEUM, OMENTUM,  AND  MESENTERY. 

Examination  of  the  Abdomen  in  General, 338 

1.  The  Omentum,  Mesentery,  and  Peritoneum, 338 

2.  Technique,       338 

3.  Inspection,       338 

4.  Palpation, 340 

5.  What  can  be  felt  Beneath  the  Normal  Abdominal  Walls,       .     .     .341 

6.  Palpable  Lesions  of  the  Belly  Walls 342 

7.  Abdominal  Tumors, 343 

8.  Percussion, 345 

Diseases  of  the  Peritoneum, ° 346 

1.  Peritonitis,  Local  or  General, 346 

2.  Ascites, 347 

3.  Cancer  and  Tuberculosis, 348 

The  Mesentery, 349 

1.  Glands, 349 

2.  Thrombosis, 349 

CHAPTER  XX. 
THE  STOMACH  LIVER,  AND  PANCREAS. 

The  Stomach, 350 

1.  Inspection  and  Palpation, 350 

2.  Estimation  of  the  Size,  Position,  Secretory  and  Motor  Power,       .  351 

3.  Examination  of  Contents, 355 

(a)   Qualitative  Tests, 356 

(6)    Quantitative  Estimation  of  Free  HCl  and  of  Total  Acidity    .     .357 

4.  Incidence  and  Diagnosis  of  Gastric  Diseases, 360 

The   Liver, 361 

(a)   Pain, 362 

(&)    Enlargement, 362 

(c)    Atrophy, 365 

{d)  Portal  Obstruction, 366 

{e)   Jaundice, 367 

(/)    Loss  of  Flesh  and  Strength, 368 


TABLE   OF   CONTENTS  xvii 

Page 

ig)    The  Infection  Group  of  Symptoms,      368 

(h)    Cerebral  Symptoms  of  Liver  Disease, 369 

The  Gall  Bladder  and  Bile  Ducts, 369 

1.  Differential  Diagnosis  of  Biliary  Colic, 369 

2.  Enlarged  Gall  Bladder, 369 

3.  Cholecystitis,       370 

The  Pancreas, 371 

1.  Cancer, 371 

2.  Acute  Pancreatic  Disease, 371 

3-  Cyst, 371 

4.  Bronzed  Diabetes, 372 

CHAPTER  XXI. 
THE  INTESTINES,  SPLEEN,  AND  KIDNEY. 

The  Intestines, 373 

1.  Data  for  Diagnosis, 373 

2.  Appendicitis, 375 

3.  Obstruction, 377 

4.  Cancer, 378 

5.  Examination  of  Contents, 378 

6.  Parasites, 380 

The  Spleen, 385 

1.  Palpation, 385 

2.  Percussion,       386 

3.  Causes  of  Enlargement, 387 

4.  Differential  Diagnosis  of  the  Various  Causes  of  Enlargement,  .    .388 
The  Kidney, 389 

1.  Incidence  and  Data,      389 

2.  Characteristics  Common  to  Most  Tumors  of  the  Kidney,   .     .     .     .390 

(a)  Malignant  Disease, 390 

(b)  Hydronephrosis  and  Cystic  Kidney, 390 

(c)  Perinephritic  Abscess, 391 

(d)  Abscess  of  the  Kidney, 391 

(e)  Floating  Kidney,      392 

3.  Renal  Colic  and  Other  Renal  Pain, 392 

4.  Examination  of  the  Urine 393 

(a)  Amount  and  Weight,       394 

(b)  Optical  Properties, 394 

(c)  Significance  of  Sediments  (Gross), 395 

5.  Pyuria, 395 

6.  Haematuria, 397 

7.  Chemical  Examination  of  the  Urine, 398 

(a)  Reaction  of  Normal  Urine, 398 

(b)  Tests  for  Albuminuria, 398 

8.  Significance  of  Albuminuria, 399 

9.  Glucosuria  and  Its  Significance, 400 


XVlii  TABLE   OF   CONTENTS 

Page 

10.  The  Acetone  Bodies, 402 

11.  Other  Constituents, 402 

12.  Microscopic  Examination  of  Urinary  Sediments, 403 

13.  Summary  of  the  Urinary  Pictures  Most  Useful  in  Diagnosis,     .     .408 

CHAPTER  XXII. 
THE  BLADDER,  RECTUM,  AND  GENITAL  ORGANS. 

The  Bladder, 410 

1.  Incidence  and  Data,       410 

2.  Distention, 410 

3.  The  Urine  as  Evidence  of  Bladder  Disease,       412 

The  Rectum,       413 

1.  Symptoms  which  should  Suggest  an  Examination, 413 

2.  Methods, 413 

3.  Results, 414 

The  Male  Genitals, 415 

1.  The  Penis, 415 

2.  The  Testes  and  Scrotum, 416 

The  Female  Genitals, 418 

1.  Methods, 418 

2.  The  External  Genitals, 418 

3.  The  Uterus, 419 

4.  The  Fallopian  Tubes, 420 

5.  The  Ovaries, 421 

CHAPTER  XXIII. 

THE  LEGS  AND  FEET. 

The  Legs, 424 

I.   Hip,       424 

II.   Groin, 424 

III.  Thigh, 425 

IV.  Knee, 429 

V.    (a)    Lower  Leg,        430 

(b)  The  Feet,       433 

(c)  The  Toes, .     .     .• 434 

CHAPTER  XXIV. 
THE  BLOOD. 

Examination  of  the   Blood, 437 

1.  Haemoglobin,       43  7 

2.  Study  of  the  Stained  Blood  Film, .• 439 

3.  Counting  the  White  Corpuscles, 445 

4.  Counting  the  Red  Corpuscles, 446 

5.  Interpretation  of  These  Data, 447 

(a)    Secondary  Anaemia, 447 

(6)    Chlorosis, 448 


TABLE   OF   CONTENTS  xix 

Page 

(c)  Pernicious  Anasmia, 448 

(d)  Leucocytosis, 449 

(e)  Lymphocytosis, 450 

(f)  Eosinophilia, 450 

(g)  Leukasmia, 451 

6.  The  Widal  Reaction, 452 

7.  The  Wasserman  Reaction, 453 

8.  Blood  Parasites, 453 

(a)  Malaria, 453 

(b)  Trypanosoma, 455 

(c)  Filaria, •    .  455 

CHAPTER  XXV. 

THE  JOINTS. 

Examination  of  the  Joints, 456 

Methods  and  Data, 456 

Technique, 457 

Diseases, 460 

Infectious  Arthritis, 461 

Atrophic  Arthritis,     .     .     .     .    ' 464 

Hypertrophic  Arthritis,     .     .  ' 466 

Gouty  Arthritis, 472 

Haemophilic  Arthritis,        472 

Relative  Frequency  of  the  Various  Joint  Lesions, 472 

CHAPTER  XXVI. 

THE  NERVOUS  SYSTEM. 

Examination  of  the  Nervous  System, 470 

I.   Disorders  of  Motion, 473 

II.   Disorders  of  Sensation, 476 

III.  Reflexes, 477 

IV.  Electrical  Reactions, 481 

V.   Speech  and  Handwriting, 482 

VI.  Trophic  Vasomotor  Disorders,    ..." 482 

VII.   The  Examination  of  Psychic  Functions;  Coma, 483 


Joint 


PHYSICAL  DIAGNOSIS. 


CHAPTER  I. 

DATA  RELATING  TO  THE  BODY  AS  A  WHOLE. 

I.  WEIGHT. 

To  weigh  the  patient  should  be  part  of  every  physical  examina- 
tion, and  every  physician's  office  should  contain  a  good  set  of  scales. 

1.  Gain  in  weight,  aside  from  seasonal  changes,  the  increase  in 
normal  growth,  and  convalescence  from  wasting  diseases,  means 
usually : 

(a)  Obesity. 

(b)  The  accumulation  of  serous  fluid  in  the  body — dropsy,  evi- 
dent or  latent. 

The  first  of  these  needs  no  comment.  Latent  accumulation  of 
fluid,  not  evident  in  the  subcutaneous  tissues  or  serous  spaces,  oc- 
curs in  some  forms  of  uncompensated  cardiac  or  renal  disease,  and 
gives  rise  to  an  increase  in  weight  which  may  delude  the  physician 
with  the  false  hope  of  an  improvement  in  the  patient's  condition, 
but  in  reality  calls  for  derivative  treatment  (diuresis,  sweating) . 

Obvious  dropsy  has,  of  course,  the  same  effect  on  the  weight 
and  the  same  significance. 

(c)  Myxoedema  is  occasionally  a  cause  of  increased  weight,  i.e.,  when 
the  myxoedematous  infiltration  is  widespread  (see  below,  page  8). 

2.  Loss  of  Weight. — The  aging  process  is  so  often  associated  with 
loss  of  weight' that  some  writers  speak  of  the  ''cachexia  of  old  age." 
In  some,  a  rapid  loss  of  superfluous  fat  may  occur  at  moderate  age, 
e.g.,  at  fifty- five,  and  may  give  rise  to  grave  apprehension  though  the 
general  health  remains  good  and  no  known  disease  develops. 

Aside  from  this   physiological  change  of  later  life,  most  cases  of 
loss  of  weight  are  due  to : 
(a)   Malnutrition. 

(&)   Loss  of  sleep  (whether  from  pain  or  other  cause) . 
(c)   Infectious  fevers  and  other  toxaemic  states. 

Under  the  head  of  malmitrition   come  the  cases  of  oesophageal 

1 


2  PHYSICAL   DIAGNOSIS 

stricture,  chronic  dyspepsia  (with  or  without  gastric  ulcer  or  dil- 
atation) and  gastric  cancer,  chronic  diarrhoea,  the  atrophies  of  in- 
fancy, diabetes  mellitus,  and  the  rare  cases  of  anorexia  nervosa. 

Loss  of  sleep  is,  I  believe,  the  chief  factor  in  the  emaciation  oc- 
curring in  many  painful  illnesses  as  well  as  in  various  other  types 
of  disease.  It  is  only  in  this  way  that  I  can  account  for  the  marked 
emaciation  in  many  cases  of  thoracic  aneurism. 

Toxaemia  is,  I  suppose,  accountable  for  part  at  least  of  the  ema- 
ciation in  typhoid,  cirrhotic  liver,  and  tuberculosis.  It  is  especially 
important  to  suspect  tuberculosis  and  look  for  it  in  any  patient  who 
has  lost  weight  without  any  obvious  cause,  for  such  a  loss  is  often 
an  early  symptom  of  the  disease. 

Accelerated  or  increased  metabolism  is  present  in  Graves'  disease 
and  may  be  one  of  the  earliest  symptoms.  Unless  the  patient  takes 
more  than  his  normal  share  of  food  he  loses  weight  steadily. 

II.  TEMPERATURE. 

The  method  of  taking  temperature  is  too  familiar  to  need  expla- 
nation, but  the  student  should  be  aware  of  the  fact  that  hysterics 
and  malingerers  can  and  often  do  raise  the  mercury  in  the  bulb  by 
various  manoeuvres,  unless  they  are  vigilantly  watched.  Dipping 
the  bulb  into  hot  water,  shaking  the  mercury  upward  toward  the 
higher  degrees  of  the  scale,  and  possibly  friction  with  the  tongue  (?) 
are  to  be  suspected. 

In  comatose  or  dyspnoeic  patients  and  in  infancy  the  temperature 
is  best  taken  by  rectum.  In  others  we  must  be  sure  that  the  lips  do 
not  remain  open  during  the  test,  so  as  to  reduce  the  temperature  of 
the  mouth. 

I.  Fever,  i.e.,  a  temperature  above  99°  F.,  has  much  more  diag- 
nostic value  in  adults  than  in  infancy  and  childhood.  In  the  latter 
it  is  often  impossible  to  make  out  any  pathological  condition  to 
account  for  a  fever.  After  childhood  the  vast  majority  of  fevers 
are  found  to  be  due  to : 

(a)  Infectious  disease  or  inflammation  of  any  type. 

(b)  Toxaemia  without  infection — a  much  less  common  and  less 
satisfactory  explanation.     Graves'  disease  is  an  example. 

(c)  Disturbance  of  heat  regulation — as  in  sunstroke,  after  the 
use  of  atropine,  and  in  nervous  excitement,  e.g.,  just  after  entering 
a  hospital.^ 

^  The  latter  event  may  also  reduce  (temporarily)  a  high  fever  to  normal  or  below  it. 
In  coma  from  any  cause  (uraemia,  cerebral  hemorrhage,  diabetic  coma)  fever  often  occurs. 


TEMPERATURE  3 

For  such  causes  we  search  when  the  thermometer  indicates  fever. 

Types  of  fever  often  referred  to  are : 

(a)  '' Continued  fever,"  one  which  does  not  return  to  normal  at 
any  period  in  the  twenty-four  hours,  as  in  many  cases  of  typhoid, 
pneumonia,  and  tuberculosis. 

{b)  ''Intermittent,"  "hectic,"  or  ''septic"  fever,  one  which  disap- 
pears once  or  more  in  twenty-four  hours,  as  in  double  tertian  mala- 
ria and  septic  fevers  of  various  types  (including  mixed  infections  in 
tuberculosis). 

A  fever  which  disappears  suddenly  and  permanently  is  said  to 
end  by  "crisis,"  while  one  which  gradually  passes  off  in  the  course 
of  several  days  ends  by  "lysis." 

Long-continued  fevers — i.e.,  those  lasting  two  weeks  or  more — 
are  usually  due  (in  the  temperate  zone)  to  one  of  three  causes: — 
Typhoid,  tuberculosis,  sepsis. 

In  I, GOG  "long  fevers"  (as  above  defined)  the  following  causes 
were  found  in  the  medical  records  of  the  Massachusetts  General 
Hospital: 

Typhoid  Fever 586  1 

Tuberculosis 192    \  926,  or  92  .6  per  cent. 

Pyogenic  Infections 148  J 

Epidemic  Meningitis 27   1 

"Influenza" 10 

Infectious  Arthritis  ("rheumatism") 9    | 

Leucaemia 5 

Cancer 4 

Syphihs 2 

Miscellaneous 17 

Since  the  7.4  per  cent,  just  listed  represent  fevers  whose  cause  is 
usually  obvious,  it  is  substantially  true  to  say  that  any  long  obscure 
fever  arising  in  the  temperate  zones  is  due  to  typhoid,  tuberculosis  or 
sepsis.  Under  sepsis  I  include  vegetative  endocarditis  ("benign" 
or  "malignant"),  all  local  inflammatory  processes  and  generalized 
bacterial  infections  with  or  without  a  known  portal  of  entry. 

2.  Subnormal  temperature  is  often  seen  in  wasting  disease  (can- 
cer), nephritis,  uncompensated  heart  disease,  and  myxoedema.  It 
is  rarely  of  diagnostic  value,  but  is  a  rough  measure  of  the  degree 
of  prostration. 

3.  Chills  (due  usually  to  a  sudden  rise  in  temperature)  are  seen 
chiefly  in.  (a)  Sepsis  of  any  type;  (6)  Malaria;  (c)  Onset  of  acute 
infections;  {d)  "  Nervous"  states. 


74,  or  7.4  per  cent. 


4  PHYSICAL   DIAGNOSIS 

After  the  passage  of  a  catheter,  after  or  during  labor,  and  after 
infusion  of  saline  solution,  a  chill  is  often  seen,  but  not  easily  ex- 
plained. 

True  chill,  with  shivering  and  chattering  teeth,  is  distinguished 
from  chilliness  without  any  shivering.  Chilliness  is  far  less  signifi- 
cant and  often  goes  without  fever;  true  chill  rarely  does. 

The  cause  of  true  chills  can  usually  be  determined  by  blood  ex- 
amination (leucocytosis,  malarial  parasites)  and  by  the  general 
physical  examination. 

4.  Night  Sweats  and  Day  Siveats. 

Sweating  in  disease  seems  to  be  conditioned  by:  (a)  Fever  (infec- 
tion);  (6)  Weakness;  (c)  vSleep. 

A  phthisical  patient  who  falls  asleep  in  the  daytime  will  sweat 
then  and  there,  and  the  sweating  will  stop  when  he  wakes.  In  ty- 
phoid fever  and  pneumonia  sweating  often  begins  in  convalescence 
when  the  temperature  is  nearly  or  quite  normal.  In  alcoholism, 
hyperthyroidism,  and  neurasthenic  states  we  sometimes  see  sweating 
without  fever. 

Sepsis,  acute  rheumatism,  and  tuberculosis  are  the  infections 
most  often  accompanied  by  sweating.  In  rickets  the  head  sweats 
especially. 


CHAPTER  II. 

THE  HEAD  AND  FACE;  THE  NECK. 
THE  HEAD  AND  FACE. 

Almost  all  that  we  can  learn  about  the  manifestations  of  disease 
on  the  head  and  face  is  to  be  learned  by  the  use  of  our  eyes,  by  inspec- 
tion, as  the  term  is.  Other  methods — percussion,  :c-ray,  palpation — 
yield  but  little.     I  shall  begin  at  the  top. 

I.  The  Cranial  Vault. 
I.   The  Shape  and  Size  of  the  Cr allium. 

The  shape  and  size  of  the  cranium  concern  us,  especially  in  children. 

(a)  Abnormally  small  crania  (microcephalia)  are  apt  to  mean  idiocy, 
especially  if  the  sutures  are  closed. 

(6)  An  abnormally  large  head  is  seen 
in  hydrocephalus  (see  Fig.  i),  asso- 
ciated with  enormous  "open"  areas 
uncovered  by  bone  and  a  peculiar 
downward  inclination  of  the  eyes,  which 
are  partly  covered  by  the  eyelids  and 
show  a  white  margin  above  the  iris. 
This  condition  is  to  be  distinguished 
from  the: 

(c)  Rachitic  head,  which  is  flatter 
at  the  vertex  and  more  protuberant 
at  the  frontal  eminences,  giving  it  a 
squarish  outline,  contrasted  with  the 
globular  shape  and  rounded  vertex  of 
the  hydrocephalic.  In  rickets  there 
are  no  changes  in  the  eyes. 

{d)  In  adult  life  an  enlargement 
of   the   skull,    due   to   bony  thickening, 

forms  part  of  the  rare  disease,  osteitis  deformans   (Paget's  disease), 
associated  with  thickening  and  bowing  of  the  long  bones  (see  Fig.  2). 

(e)   Myelomata  of  the  skull  may  or  may  not  be  accompanied  by  a 


Fig.  I. — Hydrocephalus. 


6 


PHYSICAL  DIAGNOSIS 


leuksemic  blood  and  a  greenish  staining  of  the  tumor  tissues.  They 
are  recognized  by  the  concurrent  presence  of  albumosuria,  by  the 
:x;-ray,  the  negative  Wasserman  reaction  and  finally  the  histological 
examination  of  an  excised  node  (see  Figs.  3  and  4). 

Hypernephromata  may  exhibit  a  cranial  metastasis.  With  such 
a  tumor  the  presence  of  hematuria  and  enlarged  kidney  is  suggestive. 

2.   The  Fontanels. 

The  anterior  and  larger  fontanel  remains  about  the  same  size  for 
the  first  year  of  life,  then  diminishes,  and  closes  about  the  twentieth 
month.  The  posterior  closes  in  about  six  weeks.  In  rickets,  hydro- 
cephalus, hereditary  syphilis,  and  cretinism,  the  fontanels  and  sutures 
remain  open  after  the  normal  time  limit. 


Fig.  2. — Paget's  Disease.     (Edes.)     a,  Before  onset  of  hyperostosis  cranii.     6,  After  onset 
of  hyperostosis  cranii.     c,  Later  still. 


(a)  Bulging  fontanels  mean  increased  intracranial  tension  (hydro- 
cephalus, hemorrhage,  meningitis,  or  any  acute  febrile  disease  with- 
out dyspnoea) .  (b)  Depressed  fontanels  are  seen  in  severe  diarrhoea, 
wasting  diseases,  collapsed  states,  and  acute  dyspnoeic  conditions. 


3.   The  Hair. 

(a)  A  rachitic  child  often  rubs  the  hair  off  the  back  of  its  head 
by  constant  rolling  on  the  pillow.  (This  is  associated  with  profuse 
sweating  of  the  head.)     Patchy  baldness  occurs  in  the  skin  disease 


THE   HEAD   AND   FACE  7 

alopecia  areata,  and  occasionally  over  the  painful  area  in  trigeminal 
neuralgia. 

(h)  General  loss  of  hair  occurs  normally  after  many  acute  fevers 
and  with  advancing  age.  Early  baldness  (under  thirty-iive)  is  often 
hereditary.  Syphilis  may  produce  a  rapid  loss  of  hair,  local  or  general, 
and  the  same  is  true  of  myxoedema;  but  in  both  these  diseases  the 
hair  usually  grows  again  in  convalescence. 


Fig.  3. — Multiple  Myelomata. 


Fig.  4. — Multiple  Myelomata. 


(c)  Parasites  (pediculi)  are  worth  looking  for  in  the  dirtier  classes 
and  those  associated  with  them  (teachers).  Their  eggs  adhere  to 
the  hairs  and  are  familiarly  known  as  "nits."  An  eczema  or  itching 
dermatitis  often  results. 


II.  The  Forehead. 

Scars,  eruptions,  and  bony  nodes  are  important. 

(a)  Scars  may  be  due  to  trauma  or  to  old  syphilitic  periostitis. 
The  epileptic  often  cuts  his  forehead  in  falling. 

(6)  Eruptions  often  seen  on  the  forehead  are  those  of  acne,  syphilis, 
and  smallpox.  These  may  resemble  each  other  closely,  and  are  to  be 
distinguished  by  the  history,  the  presence  of  lesions  on  other  parts  of 
the  body,  and  the  concomitant  signs  (fever,  prostration,  etc.). 


8  PHYSICAL   DIAGNOSIS 

(c)  Nodes  may  be  the  result  of  many  bumps  in  childhood  or  may 
be  caused  by  a  syphilitic  periostitis  or  neoplasms  (see  Figs.  3,  4,  5 
and  7).     The  history  must  decide. 

{d)   Evidence  of  frontal  sinusitis  may  be  found  (see  Fig.  9). 

III.  The  Face  as  a  Whole. 

Very  characteristic  even  at  a  glance  is  the  face  of  (a)  acrome- 
galia. A  strong  family  likeness  seems  to  pervade  all  well-marked 
cases   (see  Figs.  6  and  8).     The  huge,  bony  "whopper  jaw"  is  the 


Fig.  5. — Syphilis  of  the  Frontal  Bone.     (Curschmann.) 

most  striking  item,  then  the  prominent  cheek  bones,  and  the  ridge 
above  the  eyes.     The  nose  and  chin  are  very  large. 

(6)  Myxoedema  (see  Fig.  10)  is  not  so  characteristic  and  might 
easily  be  mistaken  for  nephritis  or  normal  stupidity  with  obesity. 
The  presence  of  dry  skin,  falling  hair,  mental  dulness,  and  subnormal 
temperature,  all  supervening  simultaneously  within  a  few  weeks  or 
months,  make  us  suspect  the  disease,  especially  at  or  near  the  meno- 


THE   HEAD   AND   FACE 


Fig.  6. — Acromegalia. 


■ 

^^1 

^^^^               "»  j^l 

HH 

^m^     ^"^   V 

^^^Ik.^P  y^M 

Hk  ,     .    1 

^^■|i|||a 

^^^^^^» '        ^Mb^h 

^^^^^^^1 

^^H^IK'?           ^^I 

p^^^ 

^IV'  '       ii^l 

'■i%».                ^^^H 

'""^^  ^_^^^^^^^ 

Fig    7. — Gumma  Involving  Frontal  Bone. 


10 


PHYSICAL   DIAGNOSIS 


Fig.  8. — Typical  Face  in  Acromegaly. 


Fig.  9. — Frontal  Sinusitis. 


Fig.  10. — Myxoedema. 


THE   HEAD   AND  FACE 


11 


pause.     Palpation  shows  that  the  puffiness  of  the  face  is  not  true 
oedema,  as  it  does  not  pit  on  pressure. 

(c)  Cretinism — ^the  infantile  form  of  myxoedema — can  generally 
be  recognized  by  sight  alone  (see  Figs,  ii  and  12).  Here  the  tongue 
is  often  protruded,  and  there 
are  often  pot-belly  and  deformed 
legs. 

(d)  In  adenoids  of  the  naso- 
pharynx the  child's  mouth  is 
often  open,  the  nose  looks 
pinched,  the  expression  is  stupid 
(see  Fig.  13).  There  is  a 
history  of  mouth-breathing  and 


Figs,   ii  and  12. — Cretinism. 


snoring,   with  frequent  "colds,"  a  high-arched  palate,   and  perhaps 
deafness. 

(e)  In  paralysis  agitans  the  "mask-like"  face  shows  almost  no 
change  of  expression,  whatever  the  patient  says  or  does.  The  neck 
is  usually  inclined  forward,  and  so  rigid  that  when  the  patient  wishes 


12 


PHYSICAL   DIAGNOSIS 


to  look  to  right  or  left  his  whole  body  rotates  like  a  statue  on  a  pivot. 
In  some  cases  tremor  is  absent  and  the  characteristics  just  mentioned 
are  then  of  great  importance  in  diagnosis. 

(/)  In  Graves'  disease  (exophthalmic  goitre)  the  startled  or  fright- 
ened look  is  characteristic,  though  the  expression  is  almost  wholly 
due  to  the  bulging  of  the  eyes  and  their  quick  motions  (Fig.  14). 

(g)  In  leprosy  the  general  expression  is  of  a  superabundance  of 
skin  on  the  patient's  face,  reminding  us  of  some  animal  ("leonine 
face")  (Fig.  15). 


Fig.   13. — Adenoid  Face.     (Schadle.) 


(h)  In  early  phthisis  one  often  notices  the  clear,  delicate  skin, 
fine  hair,  long  eyelashes,  wide  pupils — "appealing  eyes."  Pallor 
and  a  febrile  flush  (hectic)  come  later  in  some  cases. 

(i)  After  vomiting  the  face  has  often  a  drawn,  pinched,  anxious 
look,  which  has  often  been  supposed  to  be  characteristic  of  general 
peritonitis,  intestinal  obstruction,  or  other  diseases  accompanied  by 
vomiting;  but  I  do  not  recognize  any  single  expression  as  charac- 
teristic of  peritoneal  lesions. 

(j)  Chronic  alcoholism  may  be  shown  not  only  in  a  red  nose,  but 
oftener  in  a  peculiar,  smoothed-out  look,  due,  I  suppose,  to  an  extra 
but  evenly  distributed  accumulation  of  subcutaneous  fat. 


THE   HEAD   AND   FACE 


13 


(k)  An  (Edematous  or  swollen  face  is  much  more  easily  noticed 
by  the  patient  or  his  friends  than  by  one  who  is  not  familiar  with 
his  normal  look.  It  usually  points  to  nephritis,  but  may  occur  in 
heart  disease,  and  sometimes  (especially  in  the  morning)  without 
any  known  cause.  When  combined  with  anaemia,  the  puffy  face 
gives  a  peculiar  "pasty"  look  (chronic  diffuse  nephritis). 


Fig.   14. — Exophthalmic  Goitre.     (Meltzer.) 


Fig.   15. — Face  in  Leprosy. 


IV.  Movements  of  the  Head  and  Face. 


I.   The  Shaking  Head. 

This  occurs  often  in  old  age,  occasionally  in  paralysis  agitans 
(which  oftener  affects  the  hands),  and  in  toxic  conditions  (alcohol, 
tobacco,  opium).     In  some  cases  no  cause  can  be  found. 

2.  Spasms  of  the  Face. 

Spasms  of  the  face,  i.e.,  sudden,  quick  contractions  of  certain 
facial  muscles,  such  as  winking-spasm,  jerking  of  a  corner  of  the 
mouth,  or  sniffing,  occur  chiefly : 

(a)  As  a  matter  of  habit  without  other  disease. 

(b)  As  a  part  of  the  disease  chorea,  associated  with  similar  "  rest- 


14  PHYSICAL   DIAGNOSIS 

less"  motions  of  the  hands  and  feet.  We  often  see  these  spasms  in 
school-children ;  occasionally  in  pregnant  women. 

(c)  By  imitation,  in  schools  and  institutions,  these  spasms  may 
spread  like  an  epidemic. 

From  habit  spasms,  which  persist  for  months  or  years  in  one  or 
two  groups  of  muscles,  true  chorea  is  distinguished  by  its  involvement 
of  the  hands,  feet,  and  other  parts,  by  its  frequent  association  with 
tonsillitis,  joint  pain  and  endocarditis  (see  page  460) ,  and  by  its  short 
course  (eight  to  ten  weeks  on  the  average) . 

In  hysterical  conditions  and  hereditary  brain  defects,  various 
other  spasms  occur  (see  below,  page  472). 

V.  The  Eyes. 

I  shall  not  attempt  to  deal  with  lesions  essentially  local  (such 
as  a  "sty"),  and  shall  confine  myself  to  data  that  have  diagnostic 
value  in  relation  to  the  rest  of  the  body. 

I.  (Edema  of  the  Lids. 

CEdema  of  lids,  especially  the  lower,  often  accumulates  in  the 
night  and  is  seen  in  the  early  morning,  without  known  cause  or  after 
a  debauch.     In  other  cases  it  usually  points  to  the  existence  of: 

(a)   Nephritis  (prove  by  urinary  examination) . 

(&)   ArKBmia  (prove  by  blood  examination). 

(c)   Measles  and  whooping-cough  (eruption,  paroxysms  of  cough). 

Rarer  causes  are  trichiniasis ,  angioneurotic  oedema,  and  erysipelas. 

Trichiniasis  is  recognized  by  the  presence  of  fever,  muscular  ten- 
derness, and  an  excess  of  eosinophiles  in  the  blood. 

In  angioneurotic  oedema  there  is  usually  a  previous  history  of 
similar  transitory  swellings  in  other  parts  of  the  body. 

The  acute  onset,  red  blush,  high  fever,  and  general  prostration 
distinguish  the  oedema  of  erysipelas. 

2.  Dark  Circles  under  the  Eyes 

may  appear  in  any  debilitated  state,  e.g.,  from  loss  of  sleep,  hunger, 
menstruation,  masturbation,  etc. 

3.   Conjunctivitis. 

This  affection  forms  part  of  hay  fever,  measles,  yellow  fever, 
and  some  cases  of  influenza.     It  may  also  occur  as  an  independent 


THE   HEAD   AND  FACE  15 

infection.  It  follows  overdoses  of  iodide  of  potash  or  arsenic.  The 
whole  conjunctiva  is  reddened,  in  contradistinction  from  the  reddening 
about  the  iris  seen  in  iritis. 

4.  Jaundice. 

Jaundice,  the  yellow  coloration  of  the  white  of  the  eye  by  bile 
pigment,  is  easily  recognized  when  well  marked,  and  can  be  con- 
founded only  with  subconjunctival  fat,  which  differs  from  jaundice 
in  that  it  appears  in  spots  and  patches,  not  covering  the  whole  sclera, 
as  jaundice  does.  In  mild  cases  only  the  posterior  portions  of  the 
sclera  are  tinted  yellow,  while  the  anterior  part  around  the  iris 
may  show  a  bluish-white  tinge  in  contrast.  This  state  of  things 
is  hard  to  distinguish  from  the  appearances  seen  in  the  eyes  of  many 
apparently  healthy  people.  The  presence  of  bile  in  the  urine  often 
clears  up  the  question. 

The  skin,  mucous  membranes,  urine,  and  sweat  are  also  bile- 
stained  in  most  cases,  and  the  circulation  of  the  bile  in  the  blood 
often  produces  slow  pulse,  ztching,^  and  mental  depression.  Lack 
of  bile  in  the  gut  leads  to  flatulence  and  clay-colored  stools. 

The  commonest  causes  are:  (a)  Biliary  obstruction  (catarrh, 
stone  or  tumors  obstructing  the  bile  ducts,  hepatic  cirrhosis,  or 
syphilis  constricting  them). 

(6)  Tox(jeniia  (malaria,  sepsis,  icterus  of  the  new-born,  pernicious 
anaemia) . 

5.   The  Pupils. 

The  normal  reflexes  to  light  and  distance  are  tested  as  follows: 
Let  the  patient  face  the  light  and  cover  one  eye  with  the  hard.  On 
withdrawing  the  hand,  the  pupil  contracts.  Then  turn  the  patient 
away  from  the  light  and  let  him  look  at  the  farthest  corner  of  the 
room.  The  pupil  expands.  Make  him  look  at  your  finger  a  few 
inches  distant  from  his  eyes.  The  pupil  contracts.  Each  pupil 
should  be  examined  separately. 

The  value  of  the  pupils  in  diagnosis  has  been  greatly  overestimated. 
There  are,  in  fact,  comparatively  few  conditions  in  which  they  yield 
us  important  diagnostic  evidence,  for,  although  they  are  very  often 
abnormal,  the  abnormalities  are  seldom  characteristic  of  any  single 
pathological  condition  and  throw  little  light  on  the  diagnosis. 

^  In  gall-stone  cases  one  often  finds  itching  without  jaundice. 


16  PHYSICAL   DIAGNOSIS 

(a)  The  Argyll-Robertson  pupil  reacts  to  distance,  but  not  to  light. 
It  is  of  great  value  as  a  factor  in  the  diagnosis  of  tabes  dorsalis  and 
dementia  paralytica. 

(&)  Dilated  pupils. — (a)  Many  phthisical  patients  show  a  more 
or  less  transient  dilatation  of  one  or  both  pupils.  (6)  Blindness 
or  deficient  sight  (from  any  cause)  may  cause  dilatation  of  the  pupil, 
(c)  Other  common  causes  are  distress  or  strong  emotion  from  any 
cause,  many  fevers  and  comatose  states,  and  the  use  of  mydriatic 
drugs. 

(c)  Contracted  pupils  are  common  in  old  age  and  in  photophobia 
from  any  cause.  Disease  high  up  in  the  spinal  cord  (tabes,  general 
paralysis,  etc.)  may  produce  contraction  {spinal  myosis)  by  paralyzing 
the  sympathetic  dilators.  Aortic  aneurism  may  produce  in  the  same 
way  contraction  of  one  pupil  (see  below,  page  266). 

(d)  Contraction  with  irregular  outline  and  sluggish  reactions 
is  often  seen  in  iritis  as  a  result  of  adhesions  to  the  lens  (posterior 
synechise) . 

6.   The  Cornea. 

(a)  Arcus  senilis,  a  grayish  ring  at  the  circumference  of  the  cornea, 
is  one  of  the  classical  signs  of  old  age  and  arteriosclerosis. 

(b)  Syphilitic  keratitis,  usually  seen  in  the  hereditary  form  of 
the  disease,  produces  an  irregularly  distributed  haziness  of  the  cornea, 
usually  in  both  eyes  and  before  the  sixteenth  year.  Diagnosis  depends 
on  other  evidences  of  syphilis. 

Ocular  Motions. 

(a)  Ptosis,  or  dropping  of  the  eyelid,  is  usually  unilateral  and 
dependent  on  paralysis  of  the  third  nerve.  Its  most  frequent  cause 
is  syphilis.  The  eye  is  usually  drawn  out  by  the  action  of  the 
unparalyzed  external  rectus.  Moderate,  bilateral  ptosis  is  common 
in  hysterical  and  neurasthenic  conditions. 

(6)  Squint  (strabismus)  is  called  external  if  the  eye  turns  out, 
internal  if  it  turns  in.  Of  its  many  types  and  causes  I  mention  only 
the  acute  cases  due  to  intracranial  lesions,  such  as  tuberculous  and 
epidemic  meningitis,  syphilis,  tumors. 

(c)  Nystagmus  is  a  rapid,  usually  horizontal  oscillation  of  both 
eyeballs.  It  may  be  the  result  of  albinism  or  of  various  local  eye 
troubles,  but  is  an  important  member  of  the  symptom  group  char- 
acteristic of  multiple  sclerosis.  It  may,  however,  occur  in  many 
other  brain  lesions.     Rarely  the  oscillation  is  vertical. 


THE  HEAD  AND  FACE 


17 


The  Retina. 

The  lesions  which  are  of  greatest  interest  in  general  medicine 
are:  Retinal  hemorrhage,  optic  neuritis,  and  optic  atrophy. 

(a)  Retinal  hemorrhages,  with  or  without  other  retinal  changes, 
are  important  signs  of  nephritis,  grave  ancemias,  and  diabetes. 

{b)  Optic  neuritis  (usually  bilateral)  is  of  great  value  in  the 
diagnosis  of  brain  tumors,  tuberculous  meningitis,  and  brain  abscess. 
It  also  forms  part  of  the  lesions  in  many  cases  of  nephritis  and  diabetes. 

(c)  Optic  atrophy  may  be  the  end  result  of  any  of  the  types  of 
optic  neuritis  just  mentioned,  or  in  a  primary  form  is  important 
evidence  of  tabes  dorsalis.  Many  cases  occur  without  any  known 
cause. 


Fig.   1 6.- — Syphilitic  Depression  of  the  Nasal  Bones. 

VI.  The  Nose. 

I.  Size  and  Shape. — ^The  enlargement  of  all  the  tissues  of  the  nose 
occurring  in  acromegaly  has  already  been  mentioned.  In  myxoedema 
the  nostrils  are  sometimes  thickened  and  the  whole  nose  loses  its 
delicacy  of  shape.     A  red  nose  is  popularly  and  correctly  associated 


18 


PHYSICAL  DIAGNOSIS 


with  alcoholism,  but  in  many  cases  identical  appearances  are  produced 
by  acne  rosacea  or  by  lupus  erythematosus,  as  well  as  by  circulatory 
anomalies  without  any  other  disease. 

Falling  in  of  the  bridge  of  the  nose  may  be  due  to  syphilis  of  the 
nasal  hones,  especially  when  there  are  scars  over  the  sunken  portion, 
but  is  sometimes  present  without  any  disease.     See  Fig.  i6. 

The  small,  narrow  nose  associated  with  adenoid  growths  has  already 
been  mentioned. 

2.  The  nostrils  move  visibly  in  many  conditions  involving  dyspnoea 
(diseases  of  the  heart  and  lungs,  acute  infections,  etc.),  and  this  is 


Fig.  17. — Epithelioma. 


sometimes  useful  in  suggesting  to  the  physician  the  possibility  of 
pneumonia,  hitherto  unsuspected.  Dried  blood  in  the  nostrils  may  be 
of  value  as  evidence  of  recent  nosebleed. 

3.  Nosebleed  suggests  especially  trauma,  vascular  hypertension, 
infectious  fevers  (particularly  typhoid),  and  hemorrhagic  diseases 
(purpura,  haemophilia,  acute  leukaemia). 

4.  A  nasal  discharge  in  a  young  infant  ("  snuffles  ")  suggests  hered- 
itary syphilis.  In  adults  the  familiar  "cold  in  the  head"  may  need  a 
bacteriological  examination  to  exclude  the  possibility  of  nasal  diph- 
theria or  to  confirm  a  diagnosis  of  influenza. 


THE  HEAD  AND  FACE  19 

5.  A  small,  indolent,  long-standing  sore  on  the  nose  or  near  the 
corner  of  the  eye  should  always  suggest  epithelioma  (see  Fig.  17)  and 
tuberculosis.  Microscopic  examination  may  be  necessary  to  determine 
the  diagnosis. 

6.  The  consideration  of  local  disease  within  the  nose  does  not  fall 
within  the  scope  of  this  book,  but  is  suggested  by  local  pain,  difficulty 
in  breathing  through  the  nose,  frequent  "colds,"  and  asthma. 

(For  the  examination  of  the  ears,  see  below,  p.  470.) 

VII.  The  Lips. 

1.  Pallor  of  the  mucous  membrane  of  the  lips  suggests,  though  it 
never  proves,  anaemia.  No  diagnosis  of  anaemia  should  be  made  with- 
out at  least  testing  the  haemoglobin  (Tallqvist's  scale).  One  minute 
suffices. 

2.  Cyanosis,  a  purplish  or  slatey-blue  color  of  the  lips,  occurs  in 
some  healthy  persons  from  simple  "weathering."  When  well  marked, 
however,  it  should  always  suggest: — (a)  Heart  disease  (especially 
mitral  or  congenital  lesions) . — (6)  Lung  diseases  (especially  emphysema 
and  pneumonia). — (c)  Poisoning  by  acetanilid  or  other  coal-tar  anti- 
pyretics, producing  methaemoglobinaemia.^ 

The  last  is  easily  tested  by  noting  the  brownish  (not  red)  tint  of  the 
blood  when  soaked  into  filter  paper,  as  in  performing  Tallqvist's 
haemoglobin  test ;  the  test  should  be  confirmed  by  the  history.  Disease 
of  the  heart  or  lung  is  identified  by  physical  examination  of  the  chest. 

3.  Parted  lips,  an  open  mouth,  may  be  a  mere  habit  or  may  be  due 
to  nasal  obstruction  (adenoids).  Idiots  and  cretins  are  very  apt  to 
keep  their  mouths  open,  whether  there  is  enlargement  of  the  tongue 
or  not.  Dyspnoea  may  compel  a  patient  to  keep  his  mouth  open  so 
as  to  get  more  air. 

In  cold  weather  a  crack  or  fissure  may  appear,  usually  in  the  centre 
of  the  lower  lip,  and  in  poorly  nourished  individuals  may  persist  for 
weeks.  At  the  corners  of  the  mouth  fissures  or  cracks  may  be  due  to 
chapping  or  "cold-sores"  (herpes),  but  if  they  persist  for  weeks  in 
young  children  they  are  very  suggestive  of  syphilis.  White  linear 
scars  radiating  from  the  corners  of  the  mouth  are  presumptive  evidence 
of  healed  syphilitic  lesions,  oftenest  congenital. 

4.  The  mucous  patches  of  syphilis — ^white,  sharply  bounded  areas 
about  the  size  of  the  little-finger  nail — are  often  seen  at  the  junction 

^  Cyanosis  of  intestinal  origin  occurs  in  connection  with  certain  diseases  involving 
excessive  intestinal  decomposition.  (See  Gibson,  Quarterly  Journal  of  Medicine,  Oct., 
1907,  p.  29.) 


20 


PHYSICAL  DIAGNOSIS 


of  the  skin  with  the  labial  mucous  membrane,  especially  at  the  corners 
of  the  mouth. 

5.  Herpes  (''cold  sores  ")  is  due  to  a  lesion  of  the  Gasserian  ganglion 
with  resulting  "trophic"  disturbances  of  the  regions  supplied  by  the 
trigeminal  nerve.  Appearing  first  as  a  cluster  of  vesicles  (''water 
blisters")  which  break  and  leave  a  small  sore  near  the  mouth,  herpes 
is  to  be  distinguished  by:  (a)  its  distribution,  near  the  terminations  of 
some  branch  or  branches  of  the  trigeminal  nerve  ("herpes  frontalis, 
nasalis,  labialis");  {h)  by  its  lasting  but  a  few  days;  and  (c)  by  the 
absence  of  similar  lesions  elsewhere.  It  may  be  connected  with  a 
"cold"  (which  is  often  a  disease  of  the  trigeminus),  with  pneumonia, 
malaria  or  meningitis,  but  it  frequently  occurs  without  any  discover- 
able cause.     Herpetic  stomatitis  ("canker  sores")  may  accompany  it. 


Fig.  18. — Epithelioma  of  the  Lip. 


Fig.  19. — Chancre  of  the  Lip. 


6.  Epithelioma^  of  the  lip  and  chancre  should  be  suspected  whenever 
a  long-standing  sore  is  discovered  there.  Epithelioma  occurs  almost 
always  on  the  lower  lip  in  a  man  past  middle  life  (see  Fig.  18).  It 
lasts  longer  than  chancre,  is  slower  in  producing  glandular  enlargement 
at  the  angle  of  the  jaw,  and  is  not  associated  with  other  syphilitic 
lesions. 

7.  Chancre  of  the  lip  is  commoner  in  women  and  may  occur  at  any 
age,  especially  under  forty.  The  sore  usually  lasts  but  a  few  weeks, 
excites  early  enlargement  of  the  glands,  and  is  usually  associated  with 
other  manifestations  of  syphilis  (see  Fig.  19). 

8.  Angioneurotic  oedema  appears  as  a  sudden,  painless,  apparently 
.causeless  swelling  of  the  whole  lip   (see  Fig.  20),  which  may  attain 

'  It  does  harm  to  call  this  lesion  "cancer^'  because  this  term  is  so  firmly  associated 
in  the  lay  mind  with  metastasis,  recurrence,  and  death  that  unnecessary  suffering  may 
result  when  the  patient  or  his  family  learns  that  he  has  "cancer." 


THE  HEAD  AND  FACE 


21 


double  its  normal  size.  The  diagnosis  depends  on  the  exclusion  of  all 
known  causes  (trauma,  infection,  insect  bites)  and  on  the  history  of 
similar  swellings  (on  the  lip  or  else- 
where) in  the  past. 

9.  The  enlargetnent  of  the  lips  in 
myxoedema  and  cretinism  has  been 
mentioned  above  (page  19). 

10.  Hare-lip  is  a  vertical  slit 
(congenital  deficiency)  in  the  upper 
lip  opposite  to  the  nostril ;  it  is  often 
connected  with  an  antero-posterior 
cleft  through  the  hard  palate 
("cleft  palate").  The  lesion  may 
be  double,  leaving  a  small  island 
of  tissue  continuous  with  the  nasal 
septum  (intermaxillary  bone) . 
Diagnosis  is  made  at  a  glance. 


VIII.  The  Teeth. 


Fig.  20. — Angioneurotic  Oedema  of 
Lower  Lip. 


The  first  set  of  teeth  is  fairly  constant  in  its  order  and  date  of 
appearance.  In  Fig.  21  the  number  of  the  month  when  each  tooth 
is  most  apt  to  appear  is  marked  on  the  tooth.     The  second  set  (per- 


FiG.  21. — Diagram  Showing  the 
Month  at  which  Each  Tooth  (of  the 
First  Set)  Should  Appear. 


Fig.  22. — Notched  Incisors  in  Con- 
genital Syphilis. 


manent  teeth)  arrives  (less  regularly)  between  the  sixth  and  the 
fifteenth  year,  except  the  "wisdom  teeth,"  which  appear  about  the 
twenty-first  year. 


22  PHYSICAL  DIAGNOSIS 

1.  Rickets  or  cretinism  often  delays  dentition  considerably. 

2.  Congenital  syphilis  may  be  associated  with  deformities  of  the 
central  incisors  (permanent).     The  most  constant  is  that  shown  in 

Fig.    22. 

3.  Teeth-grinding. — Nervous,  delicate,  oversensitive  children  often 
grind  their  teeth  in  their  sleep.  There  is  no  foundation  for  the  popular 
superstition  that  this  act  indicates  "worms." 

IX.  The  Breath. 

Foul  breath  is  of tenest  due  to : 

(a)  Foul  teeth  and  gums  (neglect,  Riggs'  Disease). 

(6)   Stomatitis  of  any  variety. 

(c)  Follicular  Tonsillitis  with  cheesy  deposits  in  the  crypts. 

(d)  Gastric  fermentation  (with  or  without  constipation) . 

Rarer  causes  are  abscess  or  gangrene  of  the  lung,  in  which  the  breath 
may  be  intensely  foul;  the  source  of  the  odor  is  made  evident  by  the 
sputa. 

Acetone  breath  has  a  faintly  sweetish  odor,  which  has  been  com- 
pared to  that  of  chloroform,  new-mown  hay,  and  rotting  apples.  It 
occurs  not  only  in  diabetes,  but  in  various  conditions  involving 
starvation  (vomiting,  fevers),  and  especially,  but  not  only,  a  lack  of 
carbohydrates.^ 

In  urcemia  a  foul  odor  is  often  noticed,  and  an  ammoniacal  ("urin- 
ous") smell  has  been  mentioned  by  many  writers.  In  typhoid  and  in 
syphilis  some  persons  seem  to  detect  a  characteristic  odor,  but  the 
evidence  is  insufficient.  Alcoholic  breath  is  often  of  value  in  correcting 
the  false  statements  of  its  possessor.  In  comatose  persons  we  must 
remember  that  a  drink  may  have  been  taken  just  before  an  attack  of 
apoplexy  or  any  other  cause  for  coma,  so  that  an  alcoholic  breath  in 
comatose  patients  does  not  prove  that  the  coma  is  due  to  alcohol. 

In  poisoning  by  illuminating  gas  the  gaseous  odor  of  the  breath 
may  be  noticed. 

X.  The  Tongue. 

The  act  of  protruding  the  tongue  may  give  us  valuable  information 
on  the  condition  of  the  nervous  system. 

(a)  The  hesitating,  tremulous  tongue  of  typhoidal  states  is  very 
characteristic.     Simple  tremor  is  seen  in  alcoholism,  dementia  par- 

^  See  Taylor:  "Studies  on  an  Ash-free  Diet."  University  of  California  Publication, 
July  30th,  1904. 


THE  HEAD  AND  FACE 


23 


alytica,  and  weakness.  A  tongue  protruded  very  far  means  usually  a 
neurasthenic  individual  who  is  in  the  habit  of  examining  it  in  a  looking 
glass. 

(b)  If  the  tongiie  is  protrtided  to  one  side,  it  usually  means  facial 
paralysis  as  part  of  a  hemiplegia;  rarely  it  is  due  to  lesions  of  the 
hypoglossal  nerve  or  its  nucleus  (in  bulbar  paralysis  or  tabes) . 

(c)  A  coated  tongue  (due  mostly  to  lack  of  saliva)  is  not  often  of 
much  value  in  diagnosis,  and  there  is  no  need  to  distinguish  the 
varieties  and  colors  of  coats;  but  a  few  suggestions  may  be  obtained 
from  it.  Many  persons  who  seem  otherwise  perfectly  healthy  have 
coated  tongues  in  the  early  morning.  This  is  especially  true  in 
mouth-breathers,  in  smokers,  and  in  those  who  keep  late  hours. 

In  those  whose  tongues  are  usually  clean  the  appearance  of  a  coat 
is  associated  often  with  gastric  fermentation,  constipation,  or  fevers. 

A  clean  tongue  in  a  dyspeptic  suggests  hyperacidity  or  peptic  ulcer. 
This  point  I  have  found  of  more  value  than  any  inference  from  a 
coated  tongue. 

A  dry,   hr own- coated,  perhaps  cracked  tongue   goes   with   serious 
exhausted  states  and  wasting 
diseases  with  or  without  fever. 

{d)  Cyanosis  and  jaundice 
may  be  seen  in  the  tongue, 
but  better  elsewhere. 

(e)  Indentation  of  the  edges 
of  the  tongue  by  the  teeth 
occurs  especially  in  foul, 
neglected  mouths,  but  has  no 
diagnostic  value. 

(/)  Herpes  ("canker") 
often  occurs  on  the  tongue; 
it  begins  as  a  group  of  vesi- 
cles, but  these  rupture  so  soon  that  we  usually  see  first  a  very  small, 
grayish  ulcer  with  a  red  areola.  It  heals  in  a  day  or  two,  i.e.,  more 
quickly  than  the  syphilitic  mucous  patch  or  any  other  lesion  with 
which  it  is  likely  to  be  confounded. 

(g)  Cancer,  tuberculosis,  and  syphilis  may  attack  the  tongue  and 
form  deep,  long-standing  ulcerations.  Syphilis  can  usually  be  diag- 
nosed by  the  history,  the  presence  of  other  syphilitic  lesions,  the 
Wasserman  reaction,  and  the  therapeutic  test  (see  Fig.  23).  Cancer 
and  tuberculosis  should  be  diagnosed  by  microscopic  examination, 
though  cancer  is  more  commonly  found  in  men  (especially  smokers) 


Fig.  23. — Syphilis  of  the  Tongue. 


24  PHYSICAL  DIAGNOSIS 

past  middle  life  and  on  the  side  of  the  tongue.  A  local  reaction  after 
the  injection  of  tuberculin  may  be  of  decisive  importance. 

(h)  "Simple  ulcers"  are  due  to  irritation  from  a  tooth  or  to  trauma, 
and  heal  readily  if  their  cause  is  removed. 

(i)  Fissures  of  the  tongue  are  usually  due  to  syphilis,  which  is 
recognized  in  other  lesions. 

(j)  Leukoplakia  buccalis  (lingual  corns)  refers  to  whitish,  smooth, 
hard  patches  of  thickened  epithelium,  usually  on  the  dorsum  of  the 
tongue  in  smokers,  running  a  chronic  course  without  pain  or  ulceration, 
but  important  because  epithelioma  has  been  known  (and  not  very 
rarely)  to  develop  in  them. 

(k)  Geographic  tongue  is  a  desquamation  of  the  lingual  epithelium 
in  sinuous  or  circinate  areas,  which  spread  and  fuse  at  their  edges, 
while  the  central  portions  heal,  giving  a  look  something  like  the  moun- 
tain ranges  in  a  geographical  map.  It  usually  gives  no  trouble  unless 
the  patient's  attention  becomes  concentrated  on  it. 

(/)  Hypertrophy  of  the  tongue  has  already  been  mentioned  in 
connection  with  myxoedema  and  cretinism.  It  may  occur  independ- 
ently as  a  congenital  affection. 

XI.  The  Gums. 

(a)  A  lead  line  should  be  looked  for  in  every  patient  as  a  matter 
of  routine,  as  it  may  not  be  suggested  by  anything  in  the  patient's 
symptoms  or  history,  yet  may  be  the  key  to  the  whole  case. 

The  deposit  of  lead  sulphide  in  (not  on)  the  gums  is  not  blue,  but 
gray  or  black;  and  is  not  a  line,  but  a  series  of  dots  and  lines  arranged 
near  the  free  margin  of  the  gums  and  about  one  millimetre  from  it. 
Where  there  are  no  teeth  there  is  no  lead  line.  In  faint  or  doubtful 
cases  a  hand  lens  is  of  great  assistance  and  shows  up  the  dotted  arrange- 
ment of  the  deposit  very  clearly  (see  Fig.  24).  It  is  unfortunate 
that  the  term  "blue  line"  has  become  attached  to  these  gray-black 
dots. 

(6)  A  bismuth  line — in  poisoning  from  the  injection  of  bismuth 
paste — may  present  all  the  appearances  of  a  lead  line,  though  in  some 
cases  the  staining  is  more  diffuse  and  occurs  at  some  distance  from  a 
tooth  as  well  as  at  the  free  margin  of  the  gum.  The  analyses  of  the 
feces  and  the  history  of  the  case  serve  to  distinguish  it  from  a  lead  line. 

(c)  Sordes,  a  collection  of  epithelium,  bacteria,  and  food  particles, 
accumulates  about  the  roots  of  the  teeth  with  great  rapidity  in  febrile 
cases,  but  has  no  considerable  diagnostic  importance. 


TKE  HEAD  AND  FACE 


25 


(d)  Spongy  and  bleeding  gums  occur  as  part  of  the  disease  "  scurvy,'' 
after  overdoses  of  mercury  or  potassic  iodide,  in  various  debilitated 
states,  and  sometimes  without  known  cause.  The  teeth  are  loosened 
and  the  flow  of  saliva  is  usually  profuse.  The  stench  from  such  cases 
is  often  intolerable. 

{e)  Suppuration  about  the  roots  of  the  teeth  (pyorrhoea  alveolaris) 
is  common  in  neglected  mouths,  and  seems  in  some  cases  to  injure 
digestion,  but  in  most  cases  its  effects  appear  to  be  wholly  local. 


Fig.   24. — Lead-dots  in  the  Gums. 

(/)  Gumboil  (alveolar  abscess),  originating  in  a  carious  tooth,  is 
easily  recognized  by  the  familiar  signs  of  abscess  associated  with  a 
diseased  tooth  and  sometimes  with  a  surprising  amount  of  swelling 
of  the  face. 

(g)  "Epulis"  is  a  word  appHed  to  various  soft  tumors  springing 
from  the  jaw  bone  or  occasionally  from  the  gums  themselves.  Many 
of  them  are  sarcomatous,  but  microscopic  examination  is  necessary  to 
distinguish  these  from  fibroma,  granuloma,  and  angioma. 


XII.  The  Buccal  Cavity. 
I .   Eruptions. 

(a)  Koplik's  spots  in  measles  are  of  much  importance.  They 
appear  chiefly  in  the  inside  of  the  cheeks,  opposite  the  line  of  closure  of 
the  molars,  and  consist  of  minute,  bluish-white  spots,  each  surrounded 
by  a  red  areola  and  sometimes  fusing  into  larger  red  areas. 

(b)  The  syphilitic  mucous  patch  (see  above)  should  be  looked  for 
in  suspicious  cases,  not  only  in  easily  accessible  parts  of  the  mouth, 


26  PHYSICAL  DIAGNOSIS 

but  round  the  roots  of  the  gums,  where  the  cheeks  or  Hps  have  to  be 
pushed  away  to  afford  a  good  view. 

2.  Pigmentations. 

In  Addison's  disease  brown  spots  or  patches  often  occur  on  any 
part  of  the  mucous  membrane  of  the  mouth.  They  may  also  occur  in 
negroes  without  any  disease  and  after  ulcerations  (e.g.,  from  a  tooth), 
so  that  they  are  not  distinctive  of  Addison's  disease. 

3.   Gangrene. 

Gangrene  (stomatitis  gangrenosa,  "noma"),  a  rare  disease  of 
weakly  children;  starts  as  a  hard  red  spot  inside  the  cheek  and  usually 
not  far  from  the  corner  of  the  mouth  (see  Fig.  25).     There  is  a  swell- 


FiG.  25. 

ing  of  the  whole  cheek,  especially  under  the  eye.  The  odor  of  gan- 
grene is  usually  the  first  thing  to  make  clear  the  diagnosis.  Then  the 
gangrene  appears  externally  as  a  black  patch  on  the  cheek,  surrounded 
by  a  red  halo. 


THE  HEAD  AND  FACE  27 

XIII.  The  Tonsils  and  Pharynx. 

Method  of  Examination. — Place  the  patient  facing  a  good  light, 
natural  or  artificial.  Ask  him  to  open  his  mouth  without  protruding 
the  tongue.  Ask  him  to  say  "Ah."  Then  gently  press  down  and 
forward  on  the  dorsum  of  the  tongue  (not  too  far  back)  with  a  spoon  or 
tongue  depressor/  until  a  good  view  of  the  throat  is  obtained. 

Look  especially  for : 

1.  Inflammations  (redness,  eruptions,  spots,  or  membranes). 

2.  Ulcerations. 

3.  Swellings. 

4.  Reflexes. 

I.  Inflammations. 

(a)  General  redness  means  a  mild  or  early  pharyngitis,  but  may 
precede  severe  diseases  like  diphtheria  and  scarlet  fever. 

(&)  Yellowish-white  spots  on  the  tonsils,  more  or  less  confluent, 
mean  follicular  tonsillitis  in  the  vast  majority  of  cases,  but  only  by 
culture  can  we  exclude  diphtheria  with  certainty.  Fever  and  head- 
ache are  usually  present. 

(c)  A  membrane,  continuous  and  grayish-white  over  one  or  both 
tpnsils,  especially  if  it  extends  to  soft  palate  and  uvula,  means  diph- 
theria in  almost  every  case."  Rarely  a  similar  membrane  is  seen  in 
streptococcus  throats  with  or  without  scarlet  fever.  Cultures  alone 
can  decide. 

(d)  The  eruptions  of  smallpox  and  chickenpox  may  be  distributed 
in  the  pharynx  as  well  as  over  the  rest  of  the  respiratory  tract.  They 
are  recognized  by  association  with  more  characteristic  skin  lesions  and 
constitutional  signs. 

2.    Ulcerations. 

(a)  Deep  ulcerations  of  the  tonsils  or  soft  palate  are  oftenest  due 
to  syphilis.  Improvement  under  potassium  iodide  and  the  manifesta- 
tions of  syphilis  elsewhere  make  the  diagnosis  possible. 

^  If  the  patient  is  especially  nervous,  it  is  sometimes  well  to  let  him  press  down  his 
tongue  with  his  own  forefinger. 

2  Thrush,  a  rather  rare  disease  of  ill-nourished  infants,  due  to  a  fungus  of  the  yeast 
order,  may  produce  on  the  pharynx,  tongue,  or  in  any  part  of  the  mouth,  patches  of  white 
membrane.  As  the  disease  is  almost  wholly  local  and  without  constitutional  manifestations, 
it  is  passed  over  briefly  here. 

Streaks  of  mucus  or  bits  of  milk  coaguium  are  sometimes  mistaken  for  a  membrane. 


28  PHYSICAL  DIAGNOSIS 

(&)  Tuberculosis  may  produce  similar  deep  ulcerations,  recognized 
by  their  association  with  obvious  tuberculosis  of  the  lung  or  larynx. 
Occasionally  smaller  "miliary"  tubercles,  not  unlike  "canker  sores," 
are  seen  in  the  tonsillar  region.  Tuberculous  lesions  are  usually  very 
tender,  syphilitic  lesions  almost  free  from  tenderness.  The  chronic 
course  of  pharyngeal  tuberculosis  and  the  presence  of  other  tuber- 
culous lesions  identify  it. 

(c)  Malignant  disease  (oftenest  sarcoma)  may  attack  the  tonsil, 
and  forms  a  rapidly  growing  and  finally  ulcerating  tumor.  No  other 
lesion  of  the  tonsil  grows  so  fast  and  invades  surrounding  parts  so 
extensively  except  abscess;  in  abscess  the  pain,  fever,  and  constitu- 
tional manifestations  are  far  greater. 

3.  Swellings. 

(a)  Chronic  swollen  tonsil  (unilateral  or  bilateral)  without  fever  or 
constitutional  symptoms  represents  usually  the  residual  hypertrophy 
following  many  acute  attacks  of  tonsillitis  or  may  be  part  of  the  general 
adenoid  hypertrophy  so  common  in  children's  throats.  Rarely  it 
forms  part  of  the  leukaemic  or  pseudo-leuksemic  process. 

(b)  Acute  swollen  tonsil  is  usually  part  of  follicular  tonsillitis  (see 
above),  but  may  occur  without  spots,  and  often  accompanies  scarlet 
fever.  Swelling,  pain  in  swallowing,  and  fever  are  the  essentials  of 
diagnosis.     Our  chief  care  should  be  to  exclude : 

(c)  Tonsillar  abscess  (quinsy  sore  throat).  Here  the  swelling*  is 
usually  unilateral  and  greater  than  in  follicular  tonsillitis.  The  pain, 
which  is  often  severe,  is  continuous  and  not  merely  on  swallowing. 
Fever,  constitutional  symptoms,  and  swelling  of  the  glands  at  the 
angle  of  the  jaw  are  all  more  marked  than  in  follicular  tonsillitis.  The 
voice  is  nasal  or  suppressed,  and'there  is  often  salivation.  The  pillars 
of  the  fauces  and  the  soft  palate  take  part  in  the  swelling  and  the  throat 
may  be  almost  blocked  by  it.  The  suffering  increases  until  the  abscess 
breaks  or  is  opened.  Fluctuation  is  often  late  and  indefinite,  but 
should  always  be  sought  for. 

(d)  Retropharyngeal  Abscess. — A  swelling  in  the  back  of  the 
pharynx  near  the  vertebrae  occurs  not  infrequently  during  the  first 
year  of  life.  A  peculiar  cry  or  cough,  like  the  bark  of  a  puppy  or  the 
call  of  a  heron,  is  very  often  associated  (the  French  "cri  de  canard"). 
The  parents  are  often  unaware  that  the  throat  is  the  seat  of  the  trouble, 
and  only  digital  examination  proves  the  presence  of  bulging  and 
fluctuation,  usually  on  one  side  of  the  posterior  pharyngeal  wall. 


THE  NECK  29 

A  similar  abscess  of  chronic  course  may  complicate  cervical  caries 
(see  below,  page  32). 

(e)  Swollen  uvula,  with  transparent  oedema  of  its  tip,  often  com- 
plicates a  pharyngitis  or  any  lesion  with  violent  cough.  Elongation 
of  the  uvula  may  bring  it  into  contact  with  the  tongue  and  by  tickling 
excite  cough. 

(/)  Perforation  of  the  soft  palate  or  its  adhesion  to  the  back  of  the 
pharynx  means  syphilis  almost  invariably,  and,  as  it  may  be  the  only 
sign  of  an  old  infection,  it  is  a  valuable  piece  of  evidence. 

4.  Reflexes 

(a)  Lively  or  exaggerated  pharyngeal  reflexes,  such  that  the  patient 
gags  and  coughs  as  soon  as  one  touches  the  dorsum  of  the  tongue, 
are  seen  in  many  nervous  persons  and  in  many  alcoholics  without 
nervousness.  It  is  this  condition,  combined  with  a  smoker's  pharyn- 
gitis, that  leads  to  many  cases  of  morning  vomiting  in  alcoholics. 

(&)  Diminished  or  absent  reflexes  (with  paralysis  of  the  palate)  occur 
in  postdiphtheritic  neuritis  and  bulbar  paralysis.  Fluids  are  regurgi- 
tated through  the  nose  and  the  voice  has  a  peculiar  intonation. 

To  test  for  paralysis,  ask  the  patient  to  say  "Ah."  In  unilateral 
paralysis  one  side  of  the  palate  remains  motionless;  in  bilateral 
paralysis  the  whole  palate  is  still. 

XIV.  THE  NECK 

Long,  thin  necks  are  often  seen  in  phthisical  individuals,  and  short 
necks  in  the  emphysematous,  but  nothing  more  than  a  bare  hint  can 
be  derived  from  such  facts.  The  lesions  oftenest  searched  for  in  the 
neck  are:  i.  Enlarged  glands  (cervical  adenitis).  2.  Abscesses  and 
scars.  3.  Thyroid  tumors.  4.  Pulsations  (see  below,  page  86). 
5.  Torticollis  and  other  lesions  simulating  it.  (6)  Tuberculosis  of  the 
cervical  vertebrae. 

Rarer  lesions  will  be  mentioned  below. 

/.   Chains  of  Enlarged  Glands 

radiate  in  all  directions  from  the  angle  of  the  jaw — upward,  in  front 
of  the  ear  and  behind  it,  forward  along  the  ramus  of  the  jaw,  and 
downward  to  the  clavicle.     The  areas  drained  by  the  different  groups 
overlap  so  much  that  it  is  not  necessary  to  distinguish  them. 
The  commonest  causes  of  enlargement  are: 


30  PHYSICAL  DIAGNOSIS 

(a)  Tonsillitis  and  other  inflammations  within  or  around  the  m,outh 
(diphtheria,  the  exanthemata,  ''cankers,"  carious  teeth,  etc.) .  Glandu- 
lar swellings  due  to  these  causes  are  usually  acute  and  more  or  less 
tender;  most  of  them  disappear  in  a  fortnight  or  less,  but  some  persist 
(without  pain)  indefinitely. 

(b)  Tuberculosis;  long-standing  cervical  adenitis  in  children  and 
young  adults,  with  a  tendency  to  involve  the  skin  and  to  suppurate. 


Fig.   26. — Tubercular  Glands. 


is  usually  due  to  this  cause.     Certain  diagnosis  depends  on  microscopic 
examination,  animal  inoculation,  and  the  tuberculin  test. 

(c)  Syphilis;  small,  non-suppurating  glands,  occurring  in  the  neck 
and  about  the  occiput  in  adults,  often  accompany  syphilis,  but  the 
diagnosis  depends  on  the  presence  of  unmistakable  syphilitic  lesions 
elsewhere. 

(d)  Hodgkin's  disease;  chronic,  large,  rarely  suppurating  glands  in 
the  neck,  axillae,  and  groins,  with  slight  splenic  enlargement  and  nor- 
mal blood,  suggest  Hodgkin's  disease,  but  microscopic  examination  is 


THE  NECK 


31 


necessary  to  exclude  tuberculosis.  A  superficial  gland  can  be  excised 
under  cocaine,  with  very  little  pain. 

(e)  Lymphatic  Leukaemia.  No  distinguishing  characteristics  can 
be  found  in  the  glands,  but  any  nodular  enlargement  in  the  neck 
should  lead  us  to  examine  a  film  specimen  of  blood,  and  the  leukaemic 
blood  changes  are  easily  and  quickly  recognized. 

(/)  Malignant  disease  (near  by  or  at  a  distance)  may  enlarge  the 
cervical  glands.     Cancer  of  the  lip  or  tongue,  sarcoma  of  the  tonsil. 


Fig.   27. — Hodgkin's  Disease,  Six  Months  Duration. 

and,  among  distant  lesions,  cancer  of  the  stomach  and  sarcoma  of  the 
lung  have  caused  enlargement  of  these  glands  in  cases  under  my 
observation. 

(g)  If  the  parotid  gland  alone  is  swollen  and  there  are  fever  and 
pain  on  chewing,  the  case  is  probably  one  of  mumps,  especially  if 
there  are  other  cases  in  the  vicinity.  Malignant  disease  may  also 
attack  the  parotid. 

(h)  German  measles  may  be  accompanied  by  swelling  of  the  pos- 
terior cervical  or  occipital  glands  without  the  involvement  of  any 
other. 


32 


PHYSICAL  DIAGNOSIS 


//.  Abscess  or  Scars. 

Abscess  or  scars  in  the  sides  and  front  of  the  neck  generally  result 
from  glandular  tuberculosis;  hence  the  presence  of  scars  may  be  of 
value  in  the  diagnosis  of  doubtful  cases  with  a  suspicion  of  tubercu- 
losis in  later  life.  Aside  from  glandular  abscesses  (tuberculous  or 
septic)  it  is  rare  to  find  any  suppuration  in  the  neck,  except  in  the  nape, 
where  deep,  septic  abscess  (car- 
buncle) and  superficial  boils  are 
common.  High  Pott's  disease 
may  be  complicated  by  abscess 
(see  Figs.  28  an    29). 


Figs.  28  and  29. — Cervical  Abscess  in  Pott's  Disease.     (Bradford  and  Lovett.) 


///.   Thyroid  Tumors 

occur  chiefly  in  two  diseases: 

(a)   Simple  goitre  (unilateral  or  bilateral). 

(6)  Goitre  with  exophthalmos,  tachycardia,  and  tremor  (Graves' 
disease) . 

The  tumor  may  look  the  same  in  these  two  diseases  (see  Fig.  30) ; 
it  varies  in  outline  and  consistency  according  to  the  amount  of  gland 


THE  NECK 


33 


Fig.  30. — Simple  Goitre. 


tissue  and  fibrous  or  cystic  degeneration  that  is  present.  Owing  to  its 
connection  with  the  larynx  it  moves  up  and  down  somewhat  when  the 
patient  swallows,  but  is  not  at- 
tached to  any  other  structures 
in  the  neck.  The  enlargement 
is  often  unilateral  or  largely  so. 
If  very  vascular,  the  tumor  may 
vary  greatly  in  size  from  moment 
to  moment  or  at  certain  times 
{i.e.,  menstruation,  pregnancy). 
Since  the  normal  thyroid  can 
rarely  be  felt,  atrophy  of  the 
gland  (as  in  myxoedema)  is  un- 
recognizable. 

Cancer  or  sarcoma  have  oc- 
curred in  the  thyroid  and  may 
be  difficult  to  distinguish  from 
goitre.  Malignant  tumors  are 
usually  painful,  grow  fast,  are  accompanied  by  emaciation  and 
anaemia,  are  often  harder  and  more  nodulated  than  benign  goitres, 

and  invade  the  neighboring 
tissues  and  lymphatics.  His- 
tological examination  should 
decide  in  doubtful  cases. 

IV.  Torticollis  (Wry-neck)  and 
Other  Lesions  Resembling  It. 

(a)  Spasm  (tonic,  rarely 
clonic)  of  the  sterno-mastoid 
and  trapezius  may  be  due  to 
irritation  of  the  spinal  acces- 
sory nerve  by  swollen  glands, 
abscess,  scar,  or  tumor,  but 
more  often  occurs  without 
known  cause  ("rheumatic" 
and  "nervous"  cases).  The 
muscle  is  rigid' and  tender. 

(b)  Congenital  torticollis  (a 
counterpart    of    club-foot)    is 

due  to  shortness  of  the  muscle  without  spasm.     It  is  almost  always 
right-sided  and  associated  with  facial  asymmetry. 


Fig.  31. — Dislocation  of  the  Cervical  Vertebrae. 
(Walton.) 


34  PHYSICAL  DIAGNOSIS 

(c)  Dislocation  of  the  upper  cervical  vertebrce  causes  a  distortion  of 
the  neck  much  like  that  of  torticolHs  (see  Fig.  31).  The  diagnosis 
depends  on  the  history  of  injury,  the  absence  of  true  muscular  spasm, 
and  the  x-ray  picture. 

(d)  Compensatory  cervical  deviations:  (i)  When  there  is  marked 
lateral  curvature  of  the  spine,  with  or  without  Pott's  disease,  the  head 
may  be  inclined  so  far  to  the  opposite  side  that  torticollis  is  simulated 
(see  below,  page  72).  (2)  When  the  power  of  the  two  eyes  is  mark- 
edly different,  as  in  some  varieties  of  astigmatism,  the  head  may  be 
habitually  canted  to  one  side  to  assist  vision.  (3)  In  some  cases  due 
to  none  of  the  above  causes,  habit  or  occupation  (heavy  loads  on  one 
shoulder)  seem  to  produce  the  condition. 

(e)  Forced  attitude  from  cerebellar  disease  may  resemble  torticollis. 
The  diagnosis  depends  on  the  other  evidences  of  intracranial  disease. 

V.   Cervical  Pott's  Disease   (Vertebral  Tuberculosis) 

has  the  characteristics  alluded  to  below  in  the  section  on  joint  tuber- 
culosis, viz.,  stiffness  due  to  muscular  spasm,  malposition  of  the  bones 
and  of  the  head,  and  abscess  formation  (see  page  32). 

Diagnosis  depends  on  wry-neck  with  stiffness  of  the  muscles  of  the 
back  and  neck  and  pain  in  the  occiput — a  very  characteristic  symptom- 
group.  The  chin  is  often  supported  by  the  hand.  "Rheumatic" 
or  traumatic  torticollis,  however,  may  present  all  these  symptoms, 
and  diagnosis  may  be  impossible  without  the  aid  of  time  and  ther- 
apeutic tests. 

VI.  Branchial  Cysts  and  Fistulce. 

These,  due  to  persistence  of  parts  of  the  foetal  branchial  clefts,  are 
not  very  uncommon  (see  Fig.  32). 

A  branchial  cyst  is  a  globular  or  ovoid  fluctuating  sac,  hanging  or 
projecting  from  the  side  of  the  neck  or  the  region  of  the  hyoid  bone, 
painless  and  slow  of  growth.  It  may  transmit  the  motions  of  the 
carotids  and  be  mistaken  for  aneurism,  but  has  no  expansile  pulsation 
and  occurs  in  youth,  when  aneurism  is  practically  unknown.  Some 
such  cysts  may  be  emptied  by  external  pressure.^ 

Branchial  cysts  may  contain  serous,  mucous,  or  sero-sanguineous 
fluid,  or  hair  and  sebaceous  material,  according  as  their  lining  wall 

'  A  patient  of  mine  can  produce  a  gush  of  foul  fluid  in  the  mouth  by  pressure  over  a 
small  cyst  in  the  neck. 


THE   NECK 


35 


is  derived  from  ectoderm  or  entoderm.  Diagnosis  depends  on  the 
position  and  consistency  of  the  growth  and  on  the  results  of  aspira- 
tion. 

Branchial  fisttiUv  (congen- 
ital) may  open  externally  in 
the  neck,  and  occasionally 
are  complete  from  neck  to 
pharynx.  They  may  become 
occluded  and  suppuration 
result. 

VII.  Actinomycosis. 
Actinomycosis,   though   it 
usually  arises  in  the  lower  jaw  P^^   3 2. -Branchial  Cyst. 

bone,  may  appear  externally 

in  the  neck.  A  dense  infiltration  with  bluish-colored,  semifluctuat- 
ing  areas  in  it,  but  without  any  distinct  lumps  or  sharp  outlines,  is 
strongly  suggestive  of  actinomycosis,   and  should  always  lead  to  a 

microscopic  examination  of 
excised  portions  or  of  the  dis- 
charge. 

Fistulse  may  form,  but  are  less 
common  than  in  tuberculosis. 

VIII.  A   Cervical  Rib, 

springing  from  the  seventh  cer- 
vical vertebra  and  ending  free 
or  attached  to  the  first  thoracic 
rib,  appears  in  the  neck  as  an 
angular  fulness  which  pulsates, 
owing  to  the  presence  of  the 
subclavian  artery  on  top  of  it. 
It  rarely  produces  any  symp- 
toms and  is  generally  encoun- 
tered when  percussing  the  apex 
of  the  lung.  The  bone  can  be 
felt  behind  the  artery  by  careful 
palpation  and  demonstrated  by 
radiography.  Pain  or  wasting  in  the  arm,  and  occasionally  throm- 
bosis may  occur. 


Fig.  33. — Mediastinal  Neoplasm  with  Cervical 
Metastases  and  Obstructed  Vena  Cava. 


36 


PHYSICAL  DIAGNOSIS 


IX.  Inflammatory  or  Dropsical  Swelling  of  Neck. 

Venous      thrombosis,     mediastinal     tumors     and    inflammatory 
exudates  (see  Fig.  33a)  may  produce  oedema  in  the  neck. 


Fig.  -^^a. — Anthrax  Infection  of  the  Neck. 


CHAPTER  III. 
THE  ARMS  AND  HANDS;  THE  BACK. 
THE  ARMS. 

Most  of  the  lesions  of  these  parts  are  joint  lesions  and  are  dealt 
with  in  the  section  on  joints.  Others  fall  under  the  province  of  the 
neurologist  or  the  dermatologist,  but  must  be  briefly  mentioned  here. 

I.  Paralysis  of  One  Arm.  , 

Paralysis  of  most  or  all  the  muscles  of  one  arm  occurs  oftenest  in: 
(a)  Hemiplegia — with  paralysis  of  the  leg  and  often  of  the  face  on 
the  same  side.  (6)  Pressure  neuritis — traumatic  or  from  new  growths. 
(c)  Obstetrical  paralysis — neuritis  from  injury  during  parturition. 
{d)  Lead  or  alcoholic  neuritis — extensors  of  wrist  especially,  and  often 
in  both  arms,  {e)  Anterior  poliomyelitis — infantile  paralysis.  (/) 
Hysteria  and  traumatic  neuroses.^ 

Pressure  Neuritis. — The  history  of  the  case  is  of  the  greatest  im- 
portance. During  surgical  anaesthesia  the  brachial  plexus  or  the 
musculo-spiral  nerve  may  be  compressed,  and  paralysis  is  noted  as 
soon  as  the  patient  comes  out  of  anesthesia.  In  a  similar  way  in 
deep  sleep,  especially  drunken  sleep  with  the  arm  hanging  over  a 
bench  or  doubled  under  the  body,  the  nerves  may  be  injured.  Pres- 
sure from  a  crutch  or  from  the  head  of  the  humerus  in  fractures  or 
dislocations ,  or  even  a  violent  fall  on  the  shoulder  without  injury  of  bones, 
may  result  in  a  paralyzed  arm. 

Diagnosis  rests  on  the  history,  and  on  the  fact  that  not  only  the 
muscles  of  the  shoulder  group  and  the  extensors  of  the  wrist  are 
affected,  but  also  the  supinator  longus,  while  in  the  toxic  paralyses, 
especially  lead,  the  supinator  longus  is  spared.  To  test  the  function 
of  this  muscle,  grasp  the  patient's  wrist  with  the  thumb  side  upper- 
most, and  resist  while  he  attempts  to  flex  the  arm  at  the  elbow.  If 
the  supinator  is  intact  it  will  spring  into  relief  on  the  thumb  side  of  the 
forearm. 

'  Less  common  are  paralyses  due  to  lesions  of  the  arm  centre  in  the  cerebral  cortex 
(tumor,  softening,  cyst,  abscess,  hemorrhage,  thromboses,  or  embolism). 

37 


38 


PHYSICAL  DIAGNOSIS 


Obstetrical  Neuritis. — In  instrumental  deliveries  or  when  forcible 
traction  on  the  child's  arm  has  been  necessary,  with  or  without 
fractures,  a  paralysis  of  the  arm  often  results,  and,  what  is  important, 
is  often  not  noticed  till  some  years  later,  and  then  thought  to  have 
just  arisen;  thus  it  may  be  mistaken  for  anterior  poliomyelitis  or  other 
lesions. 

Toxic  Neuritis. — Lead  or  alcohol  produces  usually  a  weakness  of 
both  forearms,  especially  the  extensors  of  the  wrist  ("wrist-drop"), 
but  one  side  may  be  predominantly  affected  and  other  muscles  are 


Fig.  34. — Wrist  Drop,  following  Lead  Neuritis. 


involved  in  most  severe  cases.  The  history,  the  other  signs  of  lead 
poisoning,  and  the  soundness  of  the  supinator  longus  distinguish  it 
from  other  paralyses.     (See  Fig.  34.) 

All  these  forms  of  neuritis  are  apt  to  be  accompanied  by  pain, 
anaesthesia,  or  parsesthesia,  which  helps  to  distinguish  them  from 
the  cerebral  and  spinal  paralyses  next  described. 

Acute  Anterior  Poliomyelitis. — Paralysis  attacks  a  child  suddenly 
and  without  apparent  cause,  usually  after  "a  feverish  turn."  Either 
the  upper  arm  group  (deltoid,  biceps,  brachialis  anticus,  and  supinator 
longus)  or  the  lower  arm  group  (flexors  and  extensors  of  wrist  and 


THE  ARMS  39 

fingers)  may  be  affected.  The  arm  is  flabby  and  painless,  the  muscles 
waste  rapidly,  and  the  electrical  reactions  show  degeneration,  often 
within  a  week. 

Hysterical  and  Traumatic  Neuroses. — The  history  and  mode  of 
onset,  the  frequent  association  of  sensory  symptoms  which  do  not 
fit  the  distribution  of  any  peripheral  nerve,  spinal  segment,  or  cortical 
area,  the  normal  reflexes  and  electrical  reactions  distinguish  most 
cases  of  this  type,  but  diagnosis  is  sometimes  impossible. 

Paralysis  of  both  arms  is  much  less  common  than  paralysis  of  one 
arm,  and  occurs  chiefly  in  poisoning  by  lead  and  in  multiple  neuritis. 
Rarely  it  is  seen  in  the  late  stages  of  chronic  diseases  of  the  spinal  cord. 

//.   Wasting  of  One  Arm. 

(a)  Rapid  atrophy  occurs  in  all  the  types  of  neuritis  mentioned 
above,  as  well  as  in  poliomyelitis  and  progressive  muscular  atrophy. 
In  the  latter  it  occurs  without  complete  paralysis,  though  the  wasted 
muscles  are,  of  course,  weak.  Progressive  muscular  atrophy  usually 
begins  in  the  muscles  at  the  base  of  the  thumb  and  between  it  and  the 
index  finger.  Less  often  the  disease  begins  in  the  deltoid.  In  either 
case  the  rest  of  the  arm  muscles  are  later  involved. 

In  all  the  atrophies  just  mentioned  a  lack  of  the  trophic  or  nourish- 
ing functions  which  should  flow  down  the  nerve  is  assumed  to  ex- 
plain the  wasting  {"trophic  atrophy") .  From  this  we  distinguish  the 
atrophy  due  simply  to  disuse  of  the  muscles  without  nerve  lesions. 

(b)  Slow  atrophy  of  disuse  occurs  in  the  arm  in  hemiplegia,  infantile 
or  adult,  and  in  other  cerebral  lesions  involving  the  arm  centre  or  the 
fibres  leading  down  from  it. 

(c)  Cervical  rib  occasionally  leads  to  wasting  as  well  as  pain  in  the 
corresponding  arm. 

(d)  The  atrophy  often  seen  in  hysterical  cases  is  probably  due  to 
disuse  and  is  similar  to  that  occurring  in  an  arm  that  has  been  splinted 
after  fracture  or  dislocation. 

///.   Contractures  of  the  Arm. 

After  cerebral  lesions  involving  the  arm  centre,  and  in  almost  any 
spinal  or  peripheral  nerve  lesion  which  involves  one  set  of  muscles  and 
spares  another,  the  sound  muscles  contract  (or  overact)  and  permanent 
deformities  result.  In  hysteria  similar  contractures  occur.  Contrac- 
tures have  in  themselves  little  or  no  diagnostic  value,  but  indicate  a 
late  and  stubborn  stage  of  whatever  lesion  is  present. 


40  PHYSICAL  DIAGNOSIS 

IV.  CEdema  of  the  Arm} 

Causes. — -I.  Thrombosis  of  axillary  or  brachial  vein,  usually  the 
result  of  heart  disease.  2.  Pressure  of  tumors — aneurism,  cancer  of 
axillary  glands,  Hodgkin's  disease,  sarcoma  of  lung  or  mediastinum. 
3.  Nephritis,  when  the  patient  has  lain  long  on  one  side.  4.  Inflam- 
mation, usually  with  evidence  of  lymphangitis  spreading  up  the  arm 
from  a  septic  wound  on  the  hand.  5.  Deep  axillary  abscess — an 
insidious  painful  septic  focus,  not  depending  on  tuberculosis  or  on  any 
form  of  adenitis,  may  burrow  so  deeply  in  the  axilla  that  oedema  of 
the  arm  (as  well  as  pain)  is  produced.  Leucocytosis  and  slight  fever 
accompany  it.  The  diagnosis  is  easily  made  from  the  above  data 
provided  we  are  aware  of  the  existence  of  this  uncommon  but  distinct 
clinical  entity. 

The  diagnosis  of  the  cause  of  oedema  is  usually  easy  in  the  light  of 
the  facts  brought  out  by  the  general  physical  examination  (heart, 
urine,  local  lesions,  etc.). 

The  arteries  of  the  arm  (brachial  and  radial)  are  to  be  investigated 
for  changes  in  the  vessels  (see  page  88)  and  for  the  evidence  given  by 
their  pulsations  as  to  the  work  of  the  heart  (see  page  100). 

V.   Tumors  of  the  Upper  Arm. 

In  the  upper  arm  we  have:  i.  Fatty  tumors.  2.  Sarcoma  of  the 
humerus.  3.  Ruptured  biceps.  4.  Syphilitic  nodes  on  the  humerus. 
5.  Tuberculosis  of  the  humerus.  6.  Gouty  deposits  in  the  triceps 
tendon. 

Fatty  tumors  are  recognized  by  the  history  of  long  duration  and 
very  slow  growth,  by  their  superficial  position,  usually  external  to  the 
muscles,  and  soft,  lobulated  feel. 

Sarcoma  forms  the  only  large  tumor  springing  from  the  humerus. 
It  is  usually  hard  and  obviously  deep  seated  (see  Fig.  35). 

Ruptured  biceps.  The  lower  half  of  the  biceps  projects  sharply 
when  the  muscle  is  contracted,  looking  as  if  the  biceps  had  slid  down 
from  its  normal  site.  This  appearance  suddenly  following  a  wrench 
or  strain  of  the  biceps  is  diagnostic. 

Syphilitic  nodes  are  flattened  elevations  on  the  bone,  usually  about 
the  size  of  a  half-dollar,  and  feel  like  the  callus  after  a  fracture,  but 
project  only  from  one  side  of  the  bone.  There  is  pain,  especially 
at  night,   and  moderate  tenderness.     A  history  or  other  and  more 

^  Distinguished,  like  all  oedema,  by  the  fact  that  a  dent  made  by  pressing  with  the 
finger  does  not  at  once  disappear  when  the  pressure  is  removed. 


THE  ARMS 


41 


characteristic  lesion   of   syphilis   or   a   Wassermann  reaction  may  be 
necessary  for  diagnosis. 

Tuberculous  lesions^  are  much  more  common  on  the  forearm  bones, 
but  are  occasionally  seen  on  the  humerus  near  the  epiphyseal  ends. 
They  usually  involve  and  perforate  the  skin,  leaving  an  indolent,  sup- 
purating sinus  leading  to  necrosed  bone.     The  evidence  of  tuberculosis 


Fig.  35. — Sarcoma  of  Humerus. 


in  other  organs  and  the  slow,  "cold"  progress  of  the  lesion  assist  the 
diagnosis.  In  doubtful  cases  the  local  reaction  after  the  subcutaneous 
injection  of  tubercu  in  may  be  of  distinct  value.  Pain,  tenderness, 
oedema,  redness  and  heat  may  appear  or  may  be  increased  if  already 
present. 

Gouty  tophi  are  sometimes  seen  along  the  fasciae  covering  the  triceps 
tendon.     They  are  hard  and  painless.     The  diagnosis  depends  upon 

^  A  rare  disease  clinically  identical  with  tuberculosis,  but  due  to  a  wholly  different 
organism,  an  animal  parasite  resembling  a  coccidium,  has  been  described  by  Rixford, 
Gilchrist,  Montgomery,  and  other  Californian  physicians. 


42 


PHYSICAL  DIAGNOSIS 


the  peculiar  situation  of  the  lesions  and  their  association  with  other 
evidences  of  gout.^ 

VI.   Miscellaneous  Lesions  of  the  Forearm. 

Bowing  of  the  forearm  bones  occurs  in  rickets  and  in  Paget's  disease 
(see  Fig.  229).  The  lesions  in  the  other  parts  of  the  body  make  the 
diagnosrs^lear.  ^ 

Local  lesions  of  the  bones  of  the  forearm  are  chiefly  tuberculous 
and  syphilitic,  both  of  which  have  been  sufhciently  described  in  the 
last  section. 


Fig.  36. — Rachitic  Epiphysitis. 


Fig.  37. — Sarcoma  of  Ulna. 


In  the  wrist  bones  we  find: 

1.  Rachitic  enlargement  of  the  epiphyses.  In  rickets  the  terminal 
epiphyses  at  the  wrists  take  part  in  the  general  epiphyseal  enlargement 
so  common  in  the  disease.  The  diagnosis  is  easy,  for  there  is  no  other 
disease  of  infancy  producing  general  enlargement  of  the  epiphyses  (see 

Fig-  36). 

2.  Hypertrophic  pulmonary  osteoarthropathy  (Figs.  38,  39,  and  40). 
An  enlargement  of  the  lower  ends  of  the  radius  and  ulna,  with  clubbing 

'  Bursitis  over  the  olecranon  ("miner's  elbow")  produces  a  tender  fluctuating  swelling 
over  the  tip  of  the  elbow. 


THE  HANDS 


43 


of  the  fingers  (see  below,  page  53),  is  recognized  by  its  association  with 
pulmonary  or  pleural  diseases  of  many  years'  duration  (bronchiectasis, 
phthisis,  empyema). 

3.  Acromegalia  (see  page  8)  affects  chiefly  the  bones  and  soft  tissues 
of  the  hand. 

4.  Hypertrophic,  atrophic,  or  ttiherculous  disease  of  the  wrist-joint 
will  be   described   below  (see  Examinations  of  the  joints,  page  456). 

5.  ''Weeping  sinew''  or  "ganglion"  (tenosynovitis)  forms  a  fluc- 
tuating, spindle-shaped  swelling  along  one  of  the  tendons  of  the 
wrist,  slow  and  almost  painless  in  its  course.  It  may  be  tubercu- 
lous, in  which  case  the  sac  is  generally  divided  into  several  parts 
("compound  ganglion") ;  bacilli  may  occasionally  be  demonstrated  in 
the  exudate. 

6.  Neoplasms  (see  Fig.  37). 


Fig.  38. — Hypertrophic  Pulmonary  Osteo-arthropathy.     (Thayer.) 


THE  HANDS. 

I.  Evidence  of  Occupation. — The  horny,  stiffened  hands  of 
the  "son  of  toil,"  the  stains  of  paint  in  house  painters,  the  flattened, 
calloused  finger-tips  of  the  violinist,  the  worn  fingers  of  the  sewing 


44 


PHYSICAL  DIAGNOSIS 


woman,  afford  us  items  of  information  which  are  sometimes  useful 

and  worth  a  rapid  glance  in  routine  examination. 

II.   Temperature    and    Moisture. — (a)   The    cold,    moist    hand     is 

most  commonly  felt  in  "nervous"  people  under  forty.     It  is  almost 

never  seen  in  heart  disease,  which  its  possessor  often  fears,  and  does 

not  mean  "poor  circulation,"  but 
vasomotor  disturbances  of  neurotic 
origin. 

(6)  Cold,  dry  extremities — hands, 
feet,  nose,  ears — may  mean  simply 
fatigue,  exposure  to  low  tempera- 
ture, or  insufficient  exercise;  but  in 
the  course  of  chronic  disease  they 
usually  mean  weakness  of  the 
heart,  and  hence  are  serious. 

(c)  Warm,  moist  hands  are  felt 
in  Graves'  disease  (exophthalmic 
goitre),  and  if  the  warmth  and 
moisture  are  present  most  of  the 
time  and  not  only  as  a  temporary 
phase — e.g.,  after  violent  exercise 
— this  disease  is  strongly  suggested, 
and  a  search  for  tremor,  rapid 
heart,  goitre,  and  bulging  eyes 
should  be  made. 

III.  Movements  of  the  Hands. 
— (a)  The  manner  of  shaking  hands 
gives  us  vague  but  useful  impres- 
sions of  the  patient's  temperament. 
The  nervous,  cramped,  half-opened 
hand,  which  never  really  grasps 
and  gets  away  as  soon  as  possible; 
the  firm,  hearty  grasp;  the  limp, 
"wilted"  hand — furnish  hints  of 
character  that  every  physician 
must  take  account  of. 
In  fevers  or  toxgemic  states  (typhoid,  alcoholism)  there  are  two 

sets  of  movements  which  recur  so  often  that  names  have  been  given 

them,  viz.:   i.   Carphologia — picking  and  fumbling  at  the  bed  clothes. 

2.  Suhsultus  tendinum — involuntary  twitching  and  jerking  of  the  ten- 


FiG.  39. — Radiographs  of  the  Hand 
and  Arm  of  a  Case  of  Hypertrophic  Pul- 
monary Osteoarthropathy  (the  left  figure) 
compared  with  the  hand  and  arm  of  a 
normal  individual  of  the  same  height  (the 
right  figure).  Note  especially  the  thick- 
ening of  the  radius  and  ulna.     (Thayer.) 


THE  HANDS 


45 


dons  in  the  wrist  and  on  the  back  of  the  hand,  usually  associated  with 
tremor  and  carphologia. 

{b)  Tremor  of  the  Hands. — To  test  for  ordinary  tremor,  we  ask  the 
patient  to  extend  and  separate  his  fingers  widely.  The  motions  are 
then  apparent. 

Causes:  i.  Nervousness,  cold,  or  old  age.  2.  Fever  and  tox- 
aemia. 3.  Alcohol  (less  often  lead,  tobacco,  morphine,  or  other  drugs) . 
4.  Graves'  disease.  5.  Paralysis  agitans.  6.  Multiple  sclerosis.  7. 
Hysteria. 


Fig.    40. — Radiograph   of    the   Wrists   in   Hypertrophic  Pulmonary    Osteo-arthropathy. 

(v.  Ziemssen's  Atlas.) 


Most  of  these  tremors  need  no  comment.  The  intention  tremor 
of  multiple  sclerosis  (sometimes  seen  also  in  hysteria)  is  exaggerated 
into  coarse  shaking  movements  when  the  patient  tries  to  pick  up  a  pin, 
drink  a  glass  of  water,  or  do  any  other  act  calling  for  the  volitional 
coordination  of  the  small  hand  muscles.  In  the  presence  of  such  a 
tremor  we  should  look  for  nystagmus  (see  above,  page  16),  a  spastic 
gait  (see  page  473),  and  a  slow,  staccato  speech.  This  group  of  symp- 
toms suggests  multiple  (or  insular)  sclerosis. 


46 


PHYSICAL  DIAGNOSIS 


In  direct  contrast  with  this  is  the  pill-rolling  tremor  of  paralysis 
ao"itans,  which  usually  ceases  during  voluntary  movements .  The  thumb 
and  forefinger  are  near  or  touch  one  another,  and  move  as  if  they  were 
rolling  a  bread-pill.  This  tremor  is  usually  associated  with  an  immov- 
able, expressionless  face,  a  stiffened  neck  and  back,  and  a  peculiar 
attitude  and  gait  (see  below,  page  474) . 


Fig.  41. — Athetosis.     Successive  positions  of  the  hands.     (Curschmann.) 

The  other  varieties  of  tremor  can  usually  be  recognized  by  the 
history  and  associated  symptoms. 

(c)   Spasms  or  coarse  twitchings  of  the  hand  due  to : 
I.  Jacksonian   epilepsy — convulsive   attacks   which   begin   in  and 
may  remain  confined  to  one  set  of  muscles,  often  preceded  by  prick- 
ling or  other  pargesthesia  of  the  part  affected,  but  without  loss  of  con- 


THE  HANDS 


47 


sciousness.  These  muscle  spasms  are  due  usually  to  an  irritation  of 
the  corresponding  motor  area  in  the  cortex  cerebri  (tumor,  softening, 
chronic  meningitis,  etc.) ,  but  may  also  occur  in  uraemia  and  dementia 
paralytica.     Coma  and  general  spasms  may  follow. 

2.   Professional   Spasm. — Writers,    violin-players,  and  others  who 
use  one  set  of  muscles  continually  are  often  attacked  with  painful 

cramps  in  the  muscles  used 
("writer's  cramp").  Weakness  or 
semi-paralysis  of  the  muscles  may 
follow. 

3 .  Chorea  and  Choreiforyn  Move- 
ments.— True,  acute,  infectious 
chorea  (Sydenham's)  occurs  chiefly 
in  children  between  five  and  fifteen, 
generally  in  those  who  have  joint 
troubles  or  heart  disease,  and  ends 
in  eight  or  ten  weeks.     The  hands 


^^^^^^^^^^Ljg^>  fl 

^KiT^^a^^^^^H 

£ 

3r\        H^^a^B 

IK.y^  W'  i     A 

SIU 

Wiriii""MJ 

HB^^^^^^H 

■BUo^B 

^^^^^^^IH^^I 

m 

1 

Ftg.  42. — Tetany      (Masland.) 


Fig.  43. — Tetany.     (Masland.) 


are  usually  affected  first,  and  their  movements  are  like  those  of 
restlessness  and  are  quasi-purposive,  i.e.,  movements  that  might 
have  been  made  intentionally,  though  they  are  not.  At  first  sight 
one  would  surely  think  the  child  was  simply  fidgety. 

Similar  movements  occur  in  pregnant  women  or  sometimes  after 
parturition,  but  the  type  is  much  severer  and  is  apt  to  be  associated 
with  maniacal  symptoms. 

Habit  spasms  or  tics  are  much  commoner  in  the  face,  throat  and 
shoulders  but  also  reach  the  hands  occasionally.     They  constitute  an 


48 


PHYSICAL  DIAGNOSIS 


Fig.  44. — Tetany.      (Masland.) 


Fig.  45. — Tetany.     (Masland.) 


THE  HANDS 


49 


independent  chronic  neurosis  and  may  or  may  not  be  associated  with 
mental  or  emotional  disturbances.  Winking  and  nodding  movements 
are  commonest.  They  have  no  relation  to  infectious  chorea,  to  the 
joints  or  the  heart. 


Fig.  46. — Tetany.     (Masland.) 


Fig.  47. — Atrophic  Arthritis  with  "FUpper  Hand." 


Post-hemiplegic  chorea  refers  to  similar  movements  in  the  paralyzed 
hands  of  hemiplegic  cases  (children  or  adults). 

In  hysteria  or  by  a  sort  of  psychic  contagion  similar  movements  are 
4 


50 


PHYSICAL  DIAGNOSIS 


sometimes  taken  up  in  schools  and  institutions,  and  last  till  their  cause 
is  understood  and  removed. 

Chronic  choreiform  movements  occur  also  n  the  rarer  congenital 
forms  of  paralysis  with  or  without  idiocy. 

4.  Athetosis  (see  Fig.  41)  means  slow  twisting  and  bending  move- 


FiG.  48. — Spade  Hand  in  Myxcedema. 


ments   of   the  fingers,    quite   involuntary   and   always   secondary   to 
organic  cerebral  lesions  (hemiplegia,  infantile  cerebral  paralysis) . 

5.  Tetany  (see  Figs.  42,  43,  44,  45  and  46) — a  peculiar  spasm  of 
the  hands  (often  of  the  feet  as  well) ,  occuring  in  the  course  of  diseases 
of  the  stomach  and  intestine  in  children,  in  nursing  women,  after 


THE  HANDS 


51 


gastric  lavage,  and  after  thyroidectomy/  usually  lasting  minutes  or 
hours — rarely  days. 

IV.  Deformities  of  the  Hands. 

I.  "Claw  hand"  results  from  paralysis  of  the  interossei  and  lumbri- 
cales  with  contractures,  and  occurs  when  the  median  or  ulnar  nerves 
are  paralyzed,  and  in  progressive  muscular  atrophy,  syringomyelia,  and 
chronic  poliomyelitis. 


Fig.  49. — a,  Acromegalic  Hand,     b,  Normal  Hand. 


2.  ''Flipper  hand"  (see  Fig.  47),  a  common  result  of  the  contrac- 
tures in  late  cases  of  atrophic  arthritis.  Other  deformities  of  the 
fingers  are  common  in  this  disease  and  in  gout  (see  below,  page  472). 

3.  "  Hemiplegia  hand,"  a  result  of  the  contractures  following  hemi- 
plegia from  any  cause. 

4.  Myxcedema  results  in  thickening  and  coarsening  of  the  tissues 
of  the  hand  ("spade  hand ")  without  bony  enlargement;  but  the  spade 
hand  is  a  fairly  common  type  without  myxcedema,  and  one  needs  to  see 

^  When  the  parathyroid  glands  are  accidentally  removed. 


52  •  PHYSICAL  DIAGNOSIS 

it  rapidly  develop  in  connection  with  other  myxoedematous  lesions 
before  it  can  have  diagnostic  significance.  (The  same  is  true  of  the 
myxoedematous  face.)      (See  Fig.  48.) 


Fig.  50. — Atrophic  Arthriti;. 


Fig.  51. — Clubbed  Fingers. 

5.  Acromegalia  produces  general  enlargement  of  the.  bones  and 
other  tissues  of  the  hands  and  feet. 

6.  Pulmonary    Osteo-arthropathy . — ^Any    long-standing    disease    of 


THE  HANDS 


53 


the  heart,  lungs,  or  pleura  may  be  followed  by  this  peculiar  hyper- 
trophic change  in  all  the  tissues  of  the  extremities.  Mild  forms 
produce  ''clubbed  fingers,''  a  bulbous  enlargement  of  the  finger-tips 


Fig.  52. — Clubbed  Fingers. 


Fig.  53. — -Raynaud's  Disease. 


with  double  curvation  of  the  nails,  lateral  and  antero-posterior^  (see 
Fig.  51).  In  severer  forms  the  bones  of  the  hand  and  wrist  are  also 
considerably  enlarged  (see  Figs.  39  and  40). 

'  Clubbed  fingers  are  occasionally  seen  in  a  variety  of  other  diseases:  e.g.,  hepatic 
abscess,  nephritis;  and  even  in  apparently  healthy  persons. 


54  PHYSICAL  DIAGNOSIS 

7.  Heberden's  nodes,  later  described  under  the  head  of  hypertrophic 
arthritis,  are  here  pictured  (Fig.  54).  The  distinction  from  gout  has 
already  been  referred  to  (page  472). 

8.  Atrophic  arthritis   (Fig.   47)    (further  described   on   page   460) 


Fig.  54. — Heberden's  Nodes. 


Fig.  55. — Tuberculous  Dactylitis. 

presents  its  most  typical  lesions  in  the  hands  and  wrists.  The  con- 
striction line  opposite  the  articulation  is  observed  in  late  cases,  but 
ordinarily  multiple  spindle-joints  symmetrically  arranged  are  all  that 
we  see.  The  boggy  feel,  the  trophic  disturbances,  and  the  chronic 
course  are  usually  diagnostic;  but  rc-ray  examination  is  necessary  to 


THE   HANDS 


55 


establish  the  diagnosis  which  is  important  because  of  the  unfavorable 
prognosis  which  it  involves. 

9.  Syphilitic  and  tuberculous  dactylitis  (see  Fig.  55),  seen  as  a  rule 
in  young  children,  are  not  distinguished  from  each  other  by  the  physi- 
cal signs.  Diagnosis  rests  upon  the  history,  the  course,  the  Wasser- 
man  reaction,  the  results  of  giving  tuberculin  or  potassic  iodide,  and 


Fig.  56. — Morvan's  Disease. 


the  evidence  of  syphilitic  or  tuberculous  lesions  elsewhere.  In  either 
disease  we  have  a  chronic,  almost  painless,  boggy,  red  enlargement  of 
one  phalanx,  or  more,  due  to  an  indolent  inflammation  which  starts 
from  the  bone  or  periosteum  and  usually  burrows  to  the  surface,  to 
produce  a  chronic  discharging  sinus  or  ulcer. 

10.  Raynaud's  disease   attacks    the  fingers  more  often  than  any 


56 


PHYSICAL  DIAGNOSIS 


other  part.  Osier  distinguishes  three  grades  of  intensity:  A.  Loca 
syncope  ("dead  fingers")  following  exposures  to  slight  cold  or  emo- 
tional strain.  The  fingers  become  white  and  cold.  The  condition 
usually  passes  off  in  an  hour  or  two.  From  similar  causes  we  may 
have:  B.  Local  asphyxia  ("chilblains"),  producing  congestion  and 
swelling  with  or  without  pain  and  stiffness  and  with  heat  or  coldness 
of  the  part.  C.  Local  or  symmetrical  gangrene.  If  local  asphyxia 
persists,  gangrene  results.      (See  also  under  Erythromelalgia,  p.  434.) 

11.  Morvans  Disease. — ^As  a  part  of  syringomyelia  multiple 
arthropathies  (atrophic  arthritis)  and  painless  felons  may  develop  in 
the  hands    (see  Fig.   56).     The   appearances  may  strongly  suggest: 

12.  Leprosy,  in  which  there  is  likewise  anaesthetic  necrosis  of 
phalanges,  but  the  two  diseases  can  usually  be  distinguished  by  a 
study  of  the  lesions  and  symptoms  in  other  parts  of  the  body. 

13.  Dupuytren's  contraction  of  the  palmar  fascia  is  commonest  in 
adult  men,  and  gradually  produces  a  permanent,  painless  flexion  of 

the  little  finger  in  one  or  both  hands. 
A  tense  band  is  felt  in  the  palm.  The 
ring  finger  may  also  be  affected;  less 
often  the  others.  If  burn  and  felon 
are  excluded,  the  diagnosis  is  obvious. 

The  Nails  and  Finger  Tips. 

1 .  The  nutrition  of  the  nails  suffers 
in  chronic  skin  diseases,  in  myxoe- 
dema,  in  many  nerve  lesions  (neuritis, 
hemiplegia,  syringomyelia,  etc.),  de- 
mentia paralytica;  also  in  atrophic 
arthritis. 

2.  A  transverse  ridge  and  groove 
on  the  nails  often  form  when  their 
growth    is    resumed    after   an   acute 

illness.     The  movement  of  this  ridge  from  the  matrix  to  the  free  edge 
is  said  to  take  about  six  months  (see  Fig.  57). 

3.  Hang-nails  possess  a  certain  medical  interest,  because  in  some 
individuals  they  become  sore  when  the  general  condition  is  below  par, 
and  constitute  a  rough  index  of  the  degree  of  resistance  to  infection. 
They  may  become  infected  and  lead  on  to  suppuration  {paronychia) . 

4.  Indolent  sores  around  the  nail  should  rouse  the  suspicion  of 
tuberculosis  or  syphilis,  especially  in  a  child. 


Fig.  57. — Grooved  Nails  after  Acute 
Illness. 


THE  BACK  57 

5.  (a)  Cyanosis,  the  slatey  or  purplish-blue  color  of  venous  con- 
gestion, can  be  well  seen  in  the  nails,  {b)  Anaemia,  if  well  marked, 
blanches  the  tint  of  the  tissues  seen  through  the  nail,  but  the  diagnosis 
should  invariably  be  confirmed  by  a  haemoglobin  estimate. 

6.  Incurvation  of  the  nails  has  already  been  referred  to  as  a  part  of 
the  condition  known  as  "clubbed  fingers"  (page  52). 

7.  Capillary  pulse  (see  below,  page  90). 

8.  Tender  finger  ends  not  infrequently  occur  in  septic  endocarditis 
and  may  help  in  the  diagnosis  of  that  disease.  Minute  ecchymoses  are 
occasionally  present  as  well.  Both  phenomena  are,  I  suppose, 
embolic. 

THE  BACK. 

The  evidences  of  spinal  tuberculosis,  spinal  curvature,  and  of  the 
spinal  form  of  infectious  and  of  hypertrophic  arthritis  will  be  described 
later  (pages  459  and  466). 

/.  Stiff  Back. 

"Stiff  back"  may  be  due  not  only  to  the  joint  troubles  just  men- 
tioned, but  also  and  more  commonly  to  lumbago,  a  painful  affection 
of  the  lumbar  muscles  without  known  pathologic  basis.  Clinically  it 
is  characterized  by  pain  when  the  muscles  are  used,  as  in  bending 
forward  to  tie  one's  shoes  and  in  recovering  the  upright  position. 
There  is  no  bony  soreness,  no  involvement  of  the  sacro-iliac  joints,  and 
sideways  bending  is  usually  freer  than  in  hypertrophic  arthritis.  The 
pain  of  lumbago  does  not  radiate  around  the  chest  or  down  the  legs, 
and  is  not  especially  aggravated  by  coughing  or  sneezing,  but  it  some- 
times extends  down  low  into  the  fascia  of  the  lumbar  muscles  over  the 
sacrum.  The  age  of  the  patient  (usually  over  thirty)  distinguishes 
most  cases  of  lumbago  from  spinal  tuberculosis.  "Stiff  neck"  often 
accompanies  or  precedes  it  and  some  relation  to  meteoric  conditions 
can  often  be  traced.  The  disease  is  self  limited  and  should  end  in  a 
few  days  or  at  most  a  few  weeks.  Cases  of  longer  duration  are  prob- 
ably due  to  spinal  arthritis  or  tuberculosis. 

Metastatic  cancer  of  the  vertebrae  often  follows  cancer  of  the  breast 
producing  a  stiff,  painful  spine.  The  x-ray  picture  is  usually  charac- 
teristic. 

II.  Sacro-iliac  Disease. 

Tuberculosis  of  this  joint  has  long  been  known  and  calls  attention 
to  its  presence  by  pain,  psoas  spasm,  and  a  limp.     If  the  wings  of  the 


58  PHYSICAL  DIAGNOSIS 

ilium  are  forcibly  pressed  together,  the  pain  in  the  joint  is  much 
increased.  Abscess  formation  is  often  the  first  distinctive  sign.  The 
motions  at  the  hip-joint  are  not  restricted  and  the  local  signs  of  verte- 
bral caries  are  absent.  The  duration  of  the  disease,  the  local  reaction 
after  tuberculin  injection  and  the  formation  of  abscess  distinguish  it 
from  other  lesions  of  the  sacro-iliac  joint. 

Goldthwait^  has  recently  shown  that  the  sacro-iliac  joint  is  subject 
to  most  of  the  diseases  of  other  joints,  and  that  some  (e.g.,  hypertro- 
phic arthritis)  are  not  at  all  uncommon  there.  Many  of  the  pains  in 
the  back  complained  of  by  women  during  menstruation  or  in  pelvic 
disorders  are  referred  precisely  to  the  sacro-iliac  articulation  and  are 
probably  due  to  lesions  of  that  joint.  Many  cases  diagnosed  as 
"lumbago"  are  probably  due  to  one  or  another  sacro-iliac  lesion, 
strain,  sprain  or  subluxation.  The  diagnostic  points  are — on  the 
positive  side:  (a)  Pain  or  tenderness  directly  over  the  joint.  Such 
pain  may  be  elicited  by  raising  the  leg  while  the  knee  is  kept  stiff.  It  is 
also  referred  in  many  cases  to  the  course  of  the  sciatic  nerve  so  that 
many,  perhaps  most,  cases  of  so-called  sciatica  are  due  in  fact  to  sacro 
iliac  disease.  It  is  often  worse  at  night,  (b)  Abnormal  mobility  of 
the  sacro  iliac  joint,  (c)  A  tendency  to  lean  the  trunk  away  from 
the  affected  side  when  standing,  (d)  Limitation  of  lateral  bending 
of  the  spine  to  one  side  or  the  other  when  the  patient  stands  with 
the  knees  stiff. 

On  the  negative  side  the  absence  of  limitation  in  the  motions 
at  the  hip  joint,  the  negative  x-tslj,  the  free  forward  bending  (when 
the  patient  sits  during  the  test),  the  absence  of  fever,  leucocytosis  and 
abscess  formation  are  important. 

A  strong  nervous  element  is  present  in  many  cases. 

///.  Spinal  Curvatures. 

Diagnosis  is  not  difficult,  provided  we  are  led  to  examine  the  back 
at  all. 

(a)  Kyphosis  or  backward  convexity  of  the  spine,  if  sharply  an- 
gular, means  Pott's  disease  (tuberculosis).  If  the  curve  is  gentle  and 
gradual  it  may  be  due  to  "round  shoulders,"  to  hypertrophic  arthritis, 
to  emphysema,  Paget's  disease,  or  rickets.  The  rachitic  curve  is 
flaccid,  is  due  simply  to  muscular  weakness,  and  is  associated  with 
other  evidences  of  rickets.  In  emphysema  and  Paget's  disease  the 
kyphosis  goes  with  the  other  signs  of  those  diseases.  In  hypertrophic 
arthritis  the  curve  is  rigid,  irreducible,  and  usually  painless.  "  Round 
^  Goldthwait:  Boston  Medical  and  Surgical  Journal,  March  9th,  1905. 


THE  BACK  59 

shoulders"  can  be  straightened  by  muscular  exertion,  and  represent 
a  habit  of  posture. 

(6)  Lordosis,  an  exaggeration  of  the  normal  forward  convexity  of 
the  lumbar  spine,  is  seen  in  tuberculosis  of  the  hip  or  spine,  in  paralysis 
of  the  dorsal  or  abdominal  muscles  (especially  muscular  dystrophy), 
and  in  abdominal  tumors  (pregnancy),  which  need  to  be  counter- 
balanced by  backward  bending. 

(c)  Scoliosis  is  a  combination  of  lateral  curvature  with  twisting  of 
the  spine.  In  slight  or  doubtful  cases  the  tips  of  the  spinous  processes 
should  be  marked  with  a  colored  pencil,  which  makes  the  deviation 
easily  visible.     Severe  cases  cannot  be  mistaken. 

IV.  Tumors  of  the  Back. 

(a)  Aneurism  of  the  descending  aorta  may  point  in  the  back  near 
the  angle  of  the  left  scapula  (see  below,  page  270).  It  is  the  only 
pulsating  tumor  of  this  region. 

(b)  Perinephritic  abscess  usually  points  between  the  crest  of  the 
ilium  and  the  twelfth  rib,  a  few  inches  from  the  spine  (see  page  391). 

(c)  Tuberculous  abscess  ("cold  abscess"),  originating  in  vertebral 
tuberculosis,  may  point  in  the  same  region,  though  more  often  it  fol- 
lows down  the  sheath  of  the  psoas  and  points  near  Poupart's  ligament. 
"  Cold  abscess,"  starting  from  a  necrosed  rib,  is  often  seen  in  the  back. 
The  probe  leads  to  dead  bone  at  the  end  of  the  sinus.  Microscopic 
examination  of  excised  pieces  is  the  only  way  of  excluding  actinomycosis, 
though  this  disease  is  less  apt  to  form  sinuses. 

(d)  Sarcoma  of  the  scapula,  the  only  tumor  of  the  scapula  that 
is  often  seen,  occurs  in  children  and  rarely  after  the  second  decade. 
With  a  solid,  nearly  painless  tumor  of  this  bone  in  a  child,  sarcoma 
should  always  be  suspected.  Benign  exostoses  are  possible,  but 
usually  occur  later  in  life.     Histological  examination  will  decide. 

(e)  Epithelioma,  arising  from  the  skin  of  the  back,  presents  the 
ordinary  evidences  of  this  form  of  cancer. 

(/)  The  multiple  subcutaneous  abscesses  due  to  glanders  ("farcy 
buds")  are  more  common  on  the  extremities,  but  may  be  found  on  the 
trunk  as  well.  Flattened,  oval,  fluctuating  nodes  with  slight  tender- 
ness are  suggestive.  Bacteriological  examination  of  the  purulent 
contents  settles  the  diagnosis. 

I'.  Prominent  Scapula. 

This  is  due  usually  to: 

{a)  Lateral  curvature  of  the  spine  (see  above) . 


60  PHYSICAL  DIAGNOSIS 

(6)  Serratus  paralysis,  recognized  by  the  startling  prominence  of 
the  scapula  if  the  patient  pushes  forward  with  both  hands  against  re- 
sistance ("  an  gel- wing  "  scapula). 

VI.  Spina  Bifida. 

A  congenital,  saccular  tumor,  connecting  through  a  bony  defect 
with  the  interior  of  the  spinal  canal  at  any  point  between  the  occiput 
and  the  sacrum ;  nine-tenths  of  all  cases  occur  in  the  lowest  third  of  the 


Fig.  58. — Spina  Bifida  With  Meningocele. 

spinal  column.     There  is  no  other  congenital  tumor  in  this  position 
communicating  with  the  spinal  canal. 

In  the  sacral  region  there  are  other  congenital  tumors,  dermoid 
cysts,  lipomata,  and  others.  Their  nature  can  be  learned  only  by 
incision,  but  they  are  all  distinguished  from  spina  bifida  by  the  lack 
of  communication  with  the  spinal  canal. 


THE  CHEST. 


INTRODUCTION. 

I.  Methods  of  Examining  the  Thoracic  Organs. 

To  carry  out  a  thorough  examination  of  the  chest  we  do  five 
things:  i.  We  look  at  it;  technically  called  "inspection.",  2.  We 
feel  of  it;  technically  called  "palpation."  3.  We  listen  to  the  sounds 
produced  by  striking  it;  technically  called  "percussion."  4.  We 
listen  to  the  sounds  produced  within  it  by  physiological  or  pathological 
processes;  technically  called  "auscultation." 
5.  We  study  pictures  thrown  on  the  fluoroscopic 
screen  or  on  a  photographic  plate  by  the  Roentgen 
rays  as  they  traverse  the  chest;  technically 
called  "radioscopy." 

Measuring  the  dimensions  or  the  movements 
of  the  chest  ("mensuration")  is  often  mentioned 
as  co-ordinate  with  the  above  methods,  but  it 
yields  very  little  information  of  practical  value, 
and  is  at  present  very  little  used. 

Without  some  knowledge  of  the  regional 
anatomy  of  the  chest  no  intelligent  investigation 
of  the  condition  of  the  thoracic  organs  can  be 
carried  on.  Accordingly,  I  shall  begin  by  recall- 
ing very  briefly  some  of  the  most  essential 
anatomical  relations. 

II.  Regional  Anatomy  of  the  Chest. 

It  seems  to  me  a  mistake  to  divide  the  chest 
into  arbitrary  portions  and  to  describe  physical 
signs  with  reference  to  such  division.  The  seat 
of  any  lesion  can  best  be  described  by  giving  its 
relation  to  the  clavicle,  sternum,  or  ribs  on  the 
front  and  sides  of  the  chest,  and  to  the  scapulae  and  ribs  behind. 
Thus  we  may  speak  of  rales  as  heard  "above  the  left  clavicle  in 
front,"  "below  the  right  scapula  behind,"  "between  the  seventh 
and  ninth  ribs  in  the  axilla,"  and  so  on.     When  we  want  to  state 

61 


Fig.  59.— The  Mid- 
axillary  Line. 


62  PHYSICAL  DIAGNOSIS 

more  exactly  what  part  of  the  axilla  anteroposteriorly  is  affected, 
we  may  refer  to  the  "  mid-axillary  line  "  (see  Fig.  57) ;  or  better,  we  may 
place  the  lesion  by  measuring  the  number  of  centimetres  or  inches  from 
the  median  line  of  the  sternum.  In  a  similar  way  the  place  of  the 
apex  impulse  of  the  heart  (whether  in  the  normal  situation  or  farther 
toward  the  axilla)  can  be  determined  by  measuring  from  the  median 
line  of  the  sternum.  Measurements  referring  to  the  nipple  are  useless 
in  women  with  relaxed  or  hypertrophied  breasts.  But  as  a  general 
rule  they  convey  more  useful  and  reliable  information  than  measure- 
ments from  mid-sternum. 


/    p       Yr      /(/(  ^^C  '"■;  •■  /^"^   Ji\  ^\       )   \ •    Upper  lobe  of  left 

Right  auricle.  — L I'T^^i^^^V'  /^^^^-^Mir'^ "^^^^  ventricle. 

V^^^//         ^^\^^^jI  I  Lower  lobe  of  left 


Fig.  60. — Position  of  the  Heart,  Lungs,  Liver  and  Stomach.  The  dotted  lines  corre- 
spond to  the  outlines  of  the  lung;  the  heavy  continuous  line  represents  the  heart;  while 
the  position  of  the  Hver  and  of  the  lower  border  of  the  stomach  is  indicated  by  light  continu- 
ous lines.     The  ribs  are  numbered. 

If,  then,  we  confine  ourselves  chiefly  to  the  bones  of  the  chest  as 
landmarks,  and  fix,  with  reference  to  them,  the  position  of  any  portion 
of  the  internal  organs  which  we  desire  to  study,  it  becomes  unnecessary 
to  memorize  any  technical  terms  or  to  learn  the  position  of  any  arbi- 
trary lines  and  divisions  such  as  are  frequently  forced  upon  the  student. 
The  only  points  which  it  is  necessary  to  memorize  once  for  all  are : 

1 .  The  position  of  the  heart,  lungs,  liver,  and  spleen  with  reference 
to  the  bones  of  the  chest. 

2.  The  position  of  certain  points  which  experience  has  taught  us 
have  a  certain  value  in  physical  diagnosis.  I  mean  (a)  the  so-called 
"valve  areas"  of  the  heart,  which  do  not  correspond  to  the  actual 
position  of  the  valves,  for  reasons  to  be  explained  later  on,  and  (b) 


INTRODUCTION 


63 


the  percussion  outlines  of  the  heart,  liver,  and  spleen.  These  outlines 
do  not  correspond  in  size  with  the  actual  dimensions  of  the  organs 
within,  yet  there  is  a  definite  relation  between  the  two  which  remains 
relatively  constant,  so  that  we  can  infer  the  size  of  the  organ  itself  from 
the  outlines  which  we  determine  by  percussion.  The  position  of  the 
organs  themselves  is  shown  in  Figs.  60,  61,  and  62.  It  will  be  noticed 
in  Fig.  58  that  the  lungs  extend  up  above  the  clavicles  and  overlap  the 


Upper  lobe. 


_,,  Lower  lobe. 


Spleen. 

Lower  lobe. 


Upper 
lobe. 


Middle 
lobe. 


Fig.  61. — Position  of  the  Left  Lung  from  the     Fig.  62. — Position  of  the  Right  Lung  from 
Side,  and  of  the  Spleen.  the  Side,  and  of  the  Liver. 


liver  and  the  heart — ^facts  of  considerable  importance  in  the  physical 
examination  of  these  organs,  as  will  be  later  seen.  It  is  also  to  be 
noticed  how  small  a  portion  of  the  stomach  is  directly  accessible  to 
physical  examination,  the  larger  part  of  it  lying  behind  the  ribs  and 
covered  by  the  liver.  The  normal  pancreas  and  kidneys  are  practically 
inaccessible  to  physical  examination. 

The  percussion  outlines — corresponding  to  those  portions  of  the 
heart,  liver,  and  spleen  which  lie  immediately  beneath  the  chest  walls — 
will  be  illustrated  in  the  section  on  Percussion  (see  page  120). 


CHAPTER  IV. 

TECHNIQUE  AND  GENERAL  DIAGNOSIS. 

INSPECTION. 

Much  may  be  learned  b.y  a  careful  inspection  of  all  parts  of  the 
chest,  but  only  in  case  the  clothes  are  wholly  removed.  A  good  light 
is  essential,  and  this  does  not  always  mean  a  direct  light;  for  example, 
when  examining  the  front  of  the  chest  it  is  often  better  to  have  the 
patient  stand  with  his  side  to  the  window  so  that  the  light  strikes 
obliquely  across  the  chest,  accenting  every  depression  and  making 
every  pulsation  a  moving  shadow.  In  searching  for  abnormal  pulsa- 
tions, this  oblique  light  is  especially  important. 

In  examining  the  thorax  we  look  for  the  following  points: 

1.  The  size. 

2.  The  general  shape  and  nutrition. 

3.  Local  deformities  or  tumors. 

4.  The  respiratory  movements  of  the  chest  walls. 

5.  The  respiratory  movements  of  the  diaphragm. 

6.  The  normal  cardiac  movements. 

7.  Abnormal  pulsations  (arterial,  venous,  or  capillary). 

8.  The  peripheral  vessels. 

9.  The  color  and  conditions  of  the  skin  and  mucous  membranes. 

10.  The  presence  or  absence  of  glandular  enlargement. 

I.  Size. 

Small  chests  are  seen  in  patients  who  have  been  long  in  bed  from 
whatever  cause;  also  in  those  who  have  suffered  in  infancy  from 
rickets,  adenoid  growths  in  the  naso-pharynx,  or  a  combination  of  the 
two  diseases.  Abnormally  large  chests  are  seen  chiefly  in  emphysema. 
Of  course  the  chests  of  healthy  individuals  vary  a  great  deal  in  size  at 
any  given  age,  and  I  have  been  referring  in  the  last  sentences  only  to 
variations  greater  than  those  normally  found. 

II.  Shape. 

There  are  marked  differences  in  shape  between  the  child's  and  the 
adult's  chest  in  health.     A  child's  trunk,  as  compared  with  that  of 

64 


INSPECTION 


65 


an  adult,  is  far  more  nearly  cylindrical;  that  is,  the  anteroposterior 
diameter  is  nearly  as  great  as  the  lateral.  The  adult's  chest  is  dis- 
tinctly flattened  from  before  backward,  although  individual  variations 
in  this  respect  are  considerable,  as  Woods  Hutchinson  has  shown. 
In  childhood  the  commonest  pathological  modifications  are  due 
to  adenoids  or  to  rickets;  in  middle  and  later  life  to  emphysema, 
phthisis,  or  old  pleuritic  disease. 

(a)    The  Rachitic  Chest 

The  sternum  generally  projects  {"pigeon  breast"),  but  in  some 
cases,  especially  when  rickets  is  combined  with  adenoid  hypertrophy, 
there  may  be  a  depression  at  the 
root  of  the  sternum  resulting  in 
the  condition  known  as  "funnel 
breast"^  (Fig-  63).  The  sides  of 
the  chest  are  compressed  laterally 
and  slope  in  to  meet  the  sternum 
as  the  sides  of  a  ship  slope  down 
to  meet  the  keel  {pectus  carinatum) 
(Figs.  65  and  66) .  From  the  origin 
of  the  ensiform  cartilage  a  depres- 
sion or  groove  is  to  be  seen  running 
downward  and  outward  to  the 
axilla  and  corresponding  nearly  to 
the  attachment  of  the  diaphragm. 
This  is  sometimes  spoken  of  as 
"Harrison's  groove."  The  lower 
margin  of  the  ribs  in  front  often 
flares  out,  owing  to  the  enlargement 
of  the  liver  and  spleen  below  and 
the  pull  of  the  diaphragm  above. 
Along  the  line  of  the  chondro- 
costal  articulation  there  is  to  be 
felt,  and  sometimes  seen,  a  line  of 
eminences  or  swellings,  to  which  the  name  of  "rachitic  rosary"  has 
been  given. 

(6)    The  "Paralytic  Thorax." 

Fig.  67  conveys  a  better  idea  of  this  form  of  chest  than  any  descrip- 
tion.    The  normal  anteroposterior  flattening  is  exaggerated  so  that 

^  In  some  cases  this  condition  appears  to  be  congenital. 
5 


Fig.  63. — Funnel  Breast. 


66  PHYSICAL  DIAGNOSIS 

such  persons  are  spoken  of  as  ''fiat-chested."  The  clavicles  are  very- 
prominent,  owing  to  falling  in  of  the  tissues  above  and  below  them; 
the  shoulders  are  stooping,  the  scapulae  prominent,  and  the  neck  is 
generally  long.  The  angle  where  the  ribs  meet  at  the  ensiform  carti- 
lage, the  so-called  ''costal  angle,"  is  in  such  cases  very  sharp.  This 
type  of  chest  has  often  been  supposed  to  be  characteristic  of  phthisis, 
but  may  be  found  in  persons  with  perfectly  healthy  lungs.     On  the 


Fig.  64. — Acquired  Depression  at  the  Root  of  the  Ensiform  Cartilage.  The  patient 
is  a  shoemaker  of  seventy,  who  has  all  his  Ufe  pressed  against  his  breast  bone  the  shoe  on 
which  he  worked. 

other  hand,  phthisis  frequently  exists  in  persons  with  normally  shaped 
chests  or  with  abnormally  deep  chests  (Woods  Hutchinson).  (See 
Fig.   186,  page  289.) 

(c)   The  "Barrel  Chest." 

Nothing  is  less  like  a  barrel  than  the  "barrel  chest."  Its  most 
striking  characteristic  is  its  greatly  increased  anteroposterior  diameter, 
so  that  it  approaches  the  form  of  the  infant's  chest.  The  costal  angle 
is  very  obtuse,  the  shoulders  are  high,  and  the  neck  is  short.     The 


INSPECTION  67 

respiratory  movements  of  the  barrel  chest  will  be  spoken  of  later  (see 
Figs.  68  and  69). 

Nutrition  of  the  Chest  Walls. 

Emaciation  is  readily  appreciated  by  inspection.  The  ribs  are 
unusually  prominent,  the  scapulae  stand  out,  and  the  clavicles  project. 
All  this  may  be  seen  independently  of  any  change  in  the  shape  of  the 
chest  such  as  was  described  above  under  the  title  of  Paralytic  Thorax. 


Fig.  65. — Pigeon  Breast. 

Tuberculosis  of  the  apices  of  the  lungs  may  produce  a  marked  falling 
in  of  the  tissues  above  and  below  the  clavicle  independent  of  any 
emaciation  of  the  chest  itself. 

III.  Deformities. 

The  abnormalities  just  enumerated  are  symmetrical  and  affect  the 
whole  thorax.  Under  the  head  of  Deformities,  I  shall  consider  chiefly 
such  abnormalities  as  affect  particular  portions  of  the  chest  and  not 
the  thorax  as  a  whole. 

(a)   Spinal  Curvatures  and  Twists.^ 

Slight  degrees  of  deformity  are  best  seen  by  marking  with  a  skin- 
pencil  the  position  of  the  spinous  processes  (see  Fig.  71).     The  more 

^  See  also  page  58.  The  lesions  are  referred  to  here  only  in  relation  to  their  effects 
on  heart  and  lungs. 


68 


PHYSICAL  DIAGNOSIS 


marked  cases  of  lateral  curvature,  which  are  usually  accompanied  by  a 
certain  amount  of  twisting,  give  rise  to  considerable  displacement  of 
the  thoracic  organs  and  render  unreliable  the  usual  bony  landmarks, 
with  reference  to  which  we  judge  of  the  position  of  the  intrathoracic 
organs.      By  such  deformities  the  apex  of  the  heart  may  be  pushed 


Fig.  66. — Pigeon  Breast. 


Up  into  the  fourth  space  or  out  into  the  axilla,  or  portions  of  the  lungs 
may  be  compressed  and  made  atelectatic.  The  bulging  on  the  convex 
side  of  the  curve  may  simulate  an  aneurismal  tumor.  Pott's  disease 
of  the  spine  should  be  looked  for  as  a  part  of  the  routine  inspection  of 
the  chest.     It  is  sometimes  better  felt  than  seen. 

{h)   Flattening  of  One  Side  of  the  Chest. 

In  chronic  phthisis,  cirrhosis  of  the  lung,  or  long-standing  pleurisy 
(serous,  fibrous  or  purulent),  marked  falling  in  of  one  side  of  the  chest 
is  often  to  be  seen  (see  Figs.  67  and  73).  The  shrinkage  of  the 
affected  side  is  made  more  obvious  by  contrast  with  the  compensatory 


INSPECTION 


69 


hypertrophy  of  the  sound  lung,  which  makes  the  sound  side  unusually 
full  and  prominent. 

(c)  Prominence  of  One  Side  of  the  Chest. 
In  pneumothorax  or  pleural  effusions,  and  sometimes  in  malignant 
disease  of  the  lung  or  pleura,  there 
is  a  marked  increase  in  the  size  of 
the  affected  side  of  the  chest. 
Very  rarely  emphysema  may  affect 
one  lung  predominantly.  In  pneu- 
mothorax or  pleuritic  effusion  we 
usually  see,  in  addition  to  the 
above  enlargement  of  the  affected 
side,  a  smoothing  out  of  the  inter- 


FiG.  67. — The  Paralytic  Thorax. 


Fig.  68.—  ISarnl  Chest  in  a  Case  of 
Bronchial  Asthma  (set.  13) . 


costal  depressions  so  that  the  surface  of  that  side  is  much  more 
uniform  than  the  other  side.  Bulging  of  the  interspaces  from  great 
pressure  within  the  chest  rarely  occurs.     I  have  never  seen  it. 

(d)   Local  Prominences. 
In  nearly  one- quarter  of  all  healthy  chests  that  part  of  the  thoracic 
wall  which  overlies  the  heart  (the  so-called  "precordial  region")  is 


70 


PHYSICAL  DIAGNOSIS 


abnormally  prominent.  The  cause  of  this  condition  is  much  disputed. 
A  similar  prominence  may  be  brought  about  in  children  (whose 
thoracic  bones  are  very  flexible)  and  occasionally  in  older  patients, 
by  the  outward  pressure  of  an  enlarged  heart  or  of  an  effusion  in  the 
pericardial  sac.  The  prominences  due  to  spinal  curvature  have  been 
already  mentioned.     Less  common  causes  of  local  prominence  are: 

1.  Aneurism  of  the  arch  of  the  aorta. 

2.  Tumor  of  the  chest  wall  (lipoma,  sarcoma,  gumma)  or  of  the 
lung,  mediastinum,  or  of  the  thoracic  glands  pressing  their  way 
outward. 

3.  "Cold  abscess"  (tuberculosis,  actinomycosis)  of  a  rib  or  of  the 
sternum. 

4.  Empyema  perforating  the  chest  wall,  the  so-called  "empyema 
necessitatis." 


IV.  The  Respiratory  Movements. 
(a)   Normal  Respiration. 

During  normal  respiration,  one  sees  the  ribs  move  outward  and 
upward  with  inspiration,  and  downward  and  inward  with  expiration. 

Possibly  one  catches  some  hint  of  the 
movements  of  the  diaphragm  at  the 
epigastrium.  In  men,  diaphragmatic 
breathing  is  more  marked,  while  in 
women  breathing  is  mostly  of  the 
"costal  type";  that  is,  is  done  by  the 
intercostal  muscles.  In  certain  dis- 
eases an  exaggeration  of  the  costal  or 
of  the  diaphragmatic  type  of  breath- 
ing may  be  seen.  In  emphysema, 
for  example,  and  in  some  cases  of 
asthma,  the  ribs  move  very  little,  and 
most  of  the  work  of  respiration  is 
performed  by  the  diaphragm,  whose 
pull  upon  the  lower  ribs  can  some- 
times be  distinctly  seen  during  in- 
spiration. On  the  other  hand,  when 
the  movements  of  the  diaphragm  are  impeded  by  the  presence  of  fluid 
or  a  solid  tumor,  as  in  cirrhosis  of  the  liver  or  leukaemia,  the  breath- 
ing has  largely  to  be  performed  by  the  ribs,  and  becomes,  as  we  say, 
costal  in  type  (see  below,  p.  73). 


Fig.  69. — Barrel    Chest.      Chronic 
Bronchitis  and  Emphysema. 


INSPECTION 

(6)   A  nomalies  of  Expansion. 


71 


If  we  watch  the  patient  while  he  takes  a  full  breath,  we  may  notice 
certain  variations  from  the  normal  type  of  respiratory  movements. 
We  may  see:  (i)  Diminished  expansion  of  one  side  (as  a  whole,  or  at 
the  apex).      (2)   Increased  expansion  of  one  side. 

(i)  If  diminished  expansion  of  one  side  is  due  to  pleuritic  effusion, 
pneumothorax,  or  solid  tumor  of  the  lung  or  pleura,  the  affected  side 


Fig.  70. — Scoliosis. 


Fig.   71. — Scoliosis. 


is  usually  distended  as  well  as  immobile.  When,  on  the  other  hand,  the 
lung  is  retracted  or  bound  down  by  adhesions,  as  in  phthisis,  old 
pleurisy,  occlusion  of  the  bronchus,  or  from  the  pressure  of  an  aneurism, 
we  have  immobility  combined  with  a  retraction  of  the  affected  side. 
In  tuberculous  disease  at  the  apex  of  the  lungs  we  may  see  one  side 
or  both  sides  fail  to  expand  at  the  top.  Restriction  of  the  motion  of 
one  side  of  the  chest  may  also  be  due  to  pain  or  to  pressure  from  below 
the  diaphragm.  An  enlarged  liver  or  spleen  and  tumors  of  the  hepatic 
or  splenic  region  may  in  this  way  prevent  the  normal  expansion  of 


72 


PHYSICAL  DIAGNOSIS 


one  or  the  other  side  of  the  thorax.  Occasionally  a  hemiplegia  or  a 
unilateral  paralysis  of  the  diaphragm  results  in  diminished  movement 
of  one  side  of  the  chest. 

(2)  Increased  expansion  of  one  side  of  the  chest  is  observed  prin- 
cipally as  a  compensatory  or  vicarious  overfunctioning  of  that  side 
when  the  other  side  of  the  chest  is  thrown  out  of  use  by  a  large  pleuritic 
effusion,  by  pneumothorax,  long-standing  pleurisy  with  contraction, 
or  other  causes. 


(c)   Dyspnoea. 

This  term  is  often  used  rather  loosely  to  include:   (i)   Difficult 
breathing,   whether  rapid   or  slow.      (2)   Unusually  deep   breathing, 

whether  difificult  or  not.      (3) 
Rapid  breathing. 

True  dyspnoea  or  dijfLCult 
breathing  is  almost  always 
rapid  as  well,  and  does  not 
differ  at  all  from  the  well- 
known  phenomenon  of  being 
"out  of  breath"  after  a  hard 
run  or  any  violent  exertion. 
Conceive  these  conditions  as 
persisting  over  hours  or  days, 
and  we  have  the  phenomenon 
known  as  dyspnoea.  The 
breathing  is  not  only  quick 
but  labored;  that  is,  per- 
formed with  difficulty,  and 
unusual  muscles,  not  ordinar- 
ily called  upon  for  respiration, 
come  into  play  and  are  seen 
working  above  the  clavicle 
and  elsewhere.  More  or  less 
distress  is  generally  expressed 
in  the  face,  and  there  is  often 
a  blueness  of  the  lips  or  a 
dusky  color  throughout  the 
face.  The  commonest  causes  of  dyspnoea  are  the  various  forms  of 
heart  disease,  pneumonia,  large  pleuritic  effusion,  emphysema,  asthma, 
and  phthisis. 

Dyspnoea  may  affect  especially  inspiration,  as,  for  example,  when 


Fig.  72. — Lateral  Curvature.     Scoliosis. 


INSPECTION 


73 


a  foreign  body  lodges  in  the  larynx,  or  in  ordinary  "croup."  In  such 
cases  we  speak  of  ''inspiratory  dyspncea,"  distinguishing  it  from 
"expiratory  dyspnoea"  such  as  occurs  in  asthma  and  emphysema.  In 
the  latter  condition  the  breath  seems  to  enter  the  chest  readily,  but 
the  diihculty  is  to  get  it  out  again.  Expiration  is  greatly  prolonged 
and  often  noisy. 

Combined  types  in  which  both  respiratory  acts  are  difficult  are 
more  common. 


Fig.  73. — Contraction  of  Left  Chest.     Empyema. 


Abnormally  deep  and  f till  respiration,  without  any  appearance  of 
difficulty  in  the  process,  is  sometimes  seen  near  the  fatal  termination 
of  cases  of  diabetes,  the  so-called  diabetic  dyspnoea. 

Simple  rapidity  of  breathing  should  be  distinguished  from  dyspnoea 
of  any  type.  In  adults  the  normal  rate  of  respiration  is  about  18  per 
minute.  In  children,  it  is  considerably  quicker  and  more  irregular. 
It  is  not  desirable  to  attempt  here  to  enumerate  all  the  causes  which 
may  lead  to  a  quickening  of  the  respiration.  Among  the  commoner 
are  muscular  exertion,  emotion,  hysteria,  diseases  of  the  heart  and 


74 


PHYSICAL  DIAGNOSIS 


lungs,  and  fluid  or  solid  accumulations  below  the  diaphragm,  : which 
push  up  that  muscle  and  cause  it  to  encroach  abnormally  upon  the 
thoracic  cavity.  Most  of  the  infectious  fevers  are  also  apt  to  be 
accompanied  by  quickened  breathing,  especially  but  not  exclusively 
when  the  fever  is  associated  with  a  disease  of  the  heart,  lungs,  pleura, 
or  pericardium. 


Fig.  74. — Prominence  of  Right  Side.     Pleural  Effusion. 

Sucking-in  of  the  interspaces  in  the  lower  axillary  regions  or  below 
the  clavicles  may  be  seen  in  connection  with  dyspnoea  whenever  the 
lungs  are  prevented  by  some  cause  from  properly  expanding  during 
inspiration.     This  may  occur  in  obstruction  at  the  glottis.^ 


V.  Changes  in  the  Respiratory  Rhythm. 
(a)   Asthmatic  Breathing. 
In  asthma  the  normal  rhythm  is  reversed;  audible  expiration  be- 
comes longer,  instead  of  shorter,  than  inspiration.     Inspiration  may 

1  Slight  retraction  of  the  lower  interspaces  in  the  axilla  during  inspiration  is  often 
seen  in  health.     In  disease  this  phenomenon  is  greatly  exaggerated. 


INSPECTION 


75 


be  represented  only  by  a  short  gasp,  while  expiration  becomes  a  pro- 
longed wheeze  lasting  several  times  as  long  as  inspiration.  Dyspnoea 
is  usually  very  marked.  In  emphysema  we  get  very  much  the  same 
type  of  breathing  so  far  as  rhythm  is  concerned,  but  the  dyspnoea  is 
not  usually  so  extreme  and  the  auxiliary  muscles  of  respiration  are  not 
so  apt  to  be  called  into  use.  In  many  cases  of  emphysema  one  sees 
the  thorax  move  all  as  one  piece,  "en  cuirasse,"  owing  to  a  senile  fixa- 
tion of  the  bones  of  the  thorax  from  ossification  of  the  cartilaginous 
portions.  In  hereditary  syphilis  or  phthisis  this  fixation  may  occur  in 
youth  or  early  middle  age. 

(b)    Cheyne-Stokes  Breathing. 

An  anomaly  of  respiratory  rhythm  in  which  short,  recurrent  parox- 
ysms of  dyspnoea  are  preceded  and  followed  by  periods  in  which  no 
respiration  occurs  (apnoea) .  If  we  represent  the  normal  respiratory 
movement  by  an  up-and-down  line,  as  seen  in  Fig.  75,  the  Cheyne- 
Stokes  type  of  breathing  would  appear  as  in  Fig.  76.     The  period  of 


Fig.  75. — Diagram  to  Represent  Normal  Breathing-Rhythm. 

apiioea  may  last  from  one  to  ten  seconds ;  then  short,  shallow  respira- 
tions begin  and  increase  rapidly,  both  in  volume  and  in  rate,  until  a 
maximum  of  marked  dyspnoea  is  reached,  when  a  diminution  in  the 
rate  and  depth  of  the  act  begins,  and  the  patient  gradually  returns 
to  the  apnoeic  state.  The  length  of  the  whole  paroxysm  may  be  from 
30  to  70  seconds.     During  the  apnoeic  period  the  patient  is  apt  to  drop 


Fig.  76. — Cheyne-Stokes  Respiration. 


asleep  for  a  few  seconds  and  the  pupils  may  become  contracted.  When 
the  paroxysm  of  dyspnoea  is  at  its  height,  he  is  apt  to  cough  and  shift 
his  position  restlessly,  or  in  case  the  whole  phenomenon  occurs  during 
sleep  he  moves  uneasily  in  his  sleep  at  this  period.  Modified  types  of 
the  phenomenon  also  occur,  in  which  there  is  a  rhythmic  increase  and 


76  PHYSICAL  DIAGNOSIS 

decrease  in  the  depth  and  rapidity  of  respiration  but  without  any 
intervening  period  of  apnoea.  This  type  of  breathing  is  most  often 
seen  in  severe  cases  of  cardiac,  renal,  or  cerebral  disease.  Conner  has 
recorded  many  varieties  in  tuberculous  meningitis.  Respiratory 
arrhythmias  are  generally  more  marked  at  night  and  may  occur  only 
at  that  time.  In  children  they  appear  sometimes  to  be  physiological 
during  sleep.  As  a  rule,  Cheyne-Stokes  breathing  is  a  sign  of  grave 
prognostic  significance,  but  patients  have  been  known  to  recover 
completely  after  weeks  or  even  months  of  it. 

(c)   Restrained  or  ''Catchy''  Breathing. 

When  the  patient  has  a  "stitch  in  the  side,"  due  to  dry  pleurisy, 
intercostal  neuralgia,  or  to  other  causes,  the  inspiration  may  be  sud- 
denly interrupted  in  the  middle,  owing  to  a  seizure  of  pain  which  makes 
the  patient  stop  breathing  as  quickly  as  he  can.  The  same  conditions 
may  produce  very  shallow  breathing  as  the  patient  tries  to  avoid  the 
pain  which  a  full  inspiration  will  cause.  This  type  of  restrained 
breathing  is  often  seen  in  pleurisy  and  pneumonia,  and  in  the  latter 
disease  expiration  is  often  accompanied  by  a  little  moan  or  grunt  of 
discomfort. 

Shallow  and  irregular  breathing  is  often  seen  in  states  of  pro- 
found unconsciousness  from  any  cause,  such  as  apoplexy  or  poison- 
ing. A  few  deep  respirations  may  be  followed  by  a  number  of  shallow 
and  irregular  ones. 

Sterno-mastoid  breathing.  When  death  is  imminent  in  any  disease, 
the  respiration  may  become  very  irregular  and  gasping,  and  it  is  apt 
to  be  accompanied  by  a  peculiar  nodding  movement  of  the  head, 
the  chin  being  thrown  quickly  upward  during  inspiration,  and  falling 
slowly  during,  expiration.  I  have  known  but  one  patient  to  recover 
after  this  type  of  breathing  had  set  in. 

After  severe  hemorrhage  the  breathing  may  be  of  a  sighing  type 
as  well  as  very  shallow. 

{d)   Stridulous  Breathing. 

A  high-pitched,  crowing  or  barking  sound  is  heard  during  inspira- 
tion when  there  is  obstruction  of  the  entrance  of  air  at  or  near  the 
glottis.  This  type  of  breathing  occurs  in  spasm  or  oedema  of  the 
glottis,  "croup,"  laryngismus  stridulus  and  post-pharyngeal  abscess; 
it  forms  the  "whoop"  in  the  paroxysms  of  whooping-cough.  Laryn- 
geal or  tracheal  obstructions  due  to  foreign  bodies,  or  tumors  within 


INSPECTION 


77 


or  pressure  from  without  the  air-tubes,  may  cause  a  similar  type  of 
respiration.  It  is  in  these  cases  more  especially  that  we  see  the  suck- 
ing-in  of  the  interspaces  mentioned  above  (see  p.  73). 

VI.  Diaphragmatic  Movements. 

The  Phrenic  Wave. 

The  normal  movements  of  the  diaphragm  may  be  rendered  visible 
by  the  following  procedure,  suggested  by  Litten  in  1892:  The  patient 
lies  upon  his  back  with  the  chest  bared  and  the  feet  pointed  directly 
toward  a  window.  Cross  lights  must  be  altogether  excluded  by  dark- 
ening any  other  windows  which  the  room  may  contain^  (see  Fig.  yy). 
The  observer  stands  at  the  patient's  side.  As  the  ribs  rise  with  the 
movement  of  inspiration,  a  short,  narrow  shadow  moves  down  the 


Fig.  77. — Litten's  Diaphragm  Shadow.     Proper  position  of  patient  and  of  observer. 

shadow  is  best  seen  near  L. 


The 


axilla  from  about  the  seventh  to  about  the  ninth  or  tenth  rib.  During 
expiration  the  shadow  rises  again  to  the  point  from  which  it  started, 
but  is  less  easily  seen.  This  phenomenon  is  to  be  seen  on  both  sides 
of  the  chest,  less  well  in  the  back,  and  sometimes  in  the  epigastrium. 
It  is  best  seen  in  spare,  muscular  young  men,  and  is  never  absent  in 
health  except  in  those  who  are  very  fat,  or  who  cannot  or  will  not 
breathe  deeply.  The  latter  condition  occurs  in  hysteria  and  in  some 
very  stupid  persons.  In  the  observation  of  several  thousand  cases,  I 
have  never  known  it  absent  in  health  except  under  these  conditions. 

^  If  it  is  convenient  to  move  the  patient's  bed  into  the  proper  position  with  relation 
to  the  window,  or  if  the  foot-board  interferes,  or  if  the  observation  has  to  be  made  after 
dark,  a  dark  lantern  or  electric  hand  lantern  held  in  the  hand  answers  very  well. 


78 


PHYSICAL  DIAGNOSIS 


In  normal  chests,  the  excursion  of  the  shadow  is  about  two  and  a 
half  inches;  with  very  forced  breathing  three  and  a  half  inches. 
The  mechanism  of  this  phenomenon  is  best  understood  by  imagining 
a  coronal  section  of  the  thorax  as  seen  from  the  front  or  back  (see  Fig. 
78).  At  the  end  of  expiration,  the  diaphragm  lies  fiat  against  the 
thorax  from  its  attachment  up  to  about  the  sixth  rib.  During  inspira- 
tion it  "peels  off"  as  it  descends  and  allows  the  edge  of  the  lung  to 
come  down  into  the  chink  between  the  diaphragm  and  thorax.  This 
"peeling  ofif"  of  the  diaphragm  and  the  descent  of  the  lung  during 
inspiration  give  rise  to  the  moving  shadow  above  described. 

By  thus  observing  the  excursion  of  the  diaphragm  we  can  obtain 
a  good  deal  of  information  of  clinical  value. 

In  pneumonia  of  the  lower  lobe,  pleuritic  effusion,  extensive  pleu- 
ritic adhesions,  or  in  advanced  cases  of  emphysema,  the  shadow  is 
absent.  This  is  explained  by  the  fact  that  in  pneumonia,  pleuritic 
effusion,  and  emphysema  the  diaphragm  is  held  off  from  the  chest  wall 
so  that  its  movements  communicate  no  shadow.  In  pleuritic  adhe- 
sions the  movements  of  the 
diaphragm  are  prevented.  In 
early  phthisis  I  have  generally 
found  the  excursion  of  the 
diaphragm  diminished  upon 
the  affected  side,  owing  to  a 
loss  of  elasticity  in  the  affected 
lung  and  in  part  probably  to 
pleuritic  adhesions.  On  the 
other  hand,  fluid  or  solid 
tumors  below  the  diaphragm, 
unless  very  large,  do  not  pre- 
vent the  descent  of  that 
muscle,  and  so  do  not  abolish  the  diaphragm  shadow.  In  cases  in 
which  the  diagnosis  is  in  doubt  between  fluid  in  the  right  pleural 
cavity  and  an  enlargement  of  the  liver  upward  or  a  subdiaphragmatic 
abscess,  the  preservation  of  the  Litten's  phenomenon  in  the  latter 
two  affections  may  be  of  some  value  in  diagnosis.  Very  large 
accumulations  of  ascitic  fluid  may  so  far  restrain  the  diaphragmatic 
movements  that  no  shadow  can  be  seen. 

The  use  of  this  method  of  examination  tends,  to  a  certain  extent, 
to  free  us  from  the  necessity  of  using  the  rc-rays,  inasmuch  as  it 
furnishes  us  with  the  means  of  observing  the  diaphragmatic  movements, 
on  the  importance  of  which  so  much  stress  has  been  laid  by  F.  H. 


Fig.  78. — Excursion  of  the  Diaphragm  during 
Forced  Respiration.  R,  Ribs;  E,  position  of  the 
diaphragm  at  end  of  expiration;  /,  position  of 
diaphragm  at  end  of  inspiration. 


INSPECTION  79 

Williams  and  others,  much  more  easily  and  cheaply  than  with  the 
rc-rays. 

It  also  frees  us  to  a  considerable  extent  from  the  need  of  using  the 
spirometer  to  determine  the  capacity  of  the  lungs.  By  measuring 
the  excursion  of  the  phrenic  shadow  and  taking  account  of  the  thoracic 
movement,  we  obtain  a  very  fair  idea  of  the  respiratory  capacity  of  the 
individual. 


VII.  Observation  of  the  Cardiac  Movements. 

(i)    The  Normal  Cardiac  Impulse. 

With  each  systole  of  the  heart  there  may  be  seen  in  the  great 
majority  of  normal  chests  an  outward  movement  of  a  small  portion  of 
the  chest  wall  just  inside  and  below  the  left  nipple.  This  phenomenon 
is  known  as  the  cardiac  impulse.^  It  is  now  generally  admitted  that 
the  "apex  impulse"  is  caused  by  the  impact  of  a  portion  of  the  right 
ventricle  against  the  chest  wall  and  not  by  the  apex  of  the  heart  itself. 
[The  bearings  of  this  fact,  which  have  not,  I  think,  been  generally 
appreciated,  will  be  discussed  presently.]  The  position  of  the  maxi- 
mum impulse  in  adults  is  usually  in  the  fifth  intercostal  space  just 
inside  the  nipple  line.  In  children  under  the  age  of  six  it  is  often  in 
the  fourth  interspace  or  behind  the  fifth  rib;  while  in  persons  of  ad- 
vanced age  it  often  descends  as  low  as  the  sixth  interspace.  In  adults 
it  is  occasion^ally  absent  even  in  perfect  health  and  under  certain  patho- 
logical conditions  to  be  later  mentioned. 

(a)  The  position  of  the  impulse  varies  to  a  certain  extent  according 
to  the  position  of  the  body.  If  the  patient  lies  upon  the  left  side,  the 
heart's  apex  swings  out  toward  the  axilla,  so  that  the  visible  impulse 
shifts  from  one  to  two  and  one-half  inches  to  the  left  (see  Fig.  79). 
A  slight  shift  to  the  right  can  also  be  brought  about  by  lying  upon  the 
right  side,  and,  as  a  rule,  the  impulse  is  less  visible  in  the  recumbent 
than  in  the  upright  position.  Since  the  heart  is  lifted  with  each 
expiration  by  the  rise  of  the  diaphragm  and  falls  during  inspiration, 
a  corresponding  change  can  be  observed  in  the  apex  beat,  which,  in 
forced  breathing,  may  shift  as  much  as  one  interspace.  Of  the  changes 
in  the  position  of  the  impulse  brought  about  by  disease,  I  shall  speak 
in  a  later  paragraph. 

^  For  a  more  detailed  description  of  the  normal  position  of  the  cardiac  impulse,  see 
next  page. 


80 


PHYSICAL  DIAGNOSIS 


(&)  Relation  of  the  maximum  cardiac  impulse  to  the  apex  of  the 
heart. — ^I  mentioned  above  that  the  maximum  cardiac  impulse  is  not 
due  to  the  striking  of  the  apex  of  the  heart  against  the  chest  wall,  but 
to  the  impact  of  a  portion  of  the  right  ventricle.  The  practical  import 
ance  of  this  fact  is  this :  When  we  are  trying  to  localize  the  apex  of 
the  heart  in  order  to  determine  how  far  the  organ  extends  to  the  left 
and  downward,  it  will  not  do  to  be  guided  by  the  position  of  the 
maximum  impulse,  for  the  apex  of  the  heart  is  almost  always  to  be 


Fig.  79. — Showing  Amount  of  Shifting  of  the  Apex  Impulse  with  Change  of  Position. 
The  inner  dot  represents  the  position, of  the  impulse  when  the  patient  lies  on  his  back; 
the  outer  dot  corresponds  to  the  position  of  the  apex  with  patient  on  left  side. 


found  three-fourths  of  an  inch  or  more  farther  to  the  left  (see  Fig.  80) . 
This  may  be  proved  by  percussion  (vide  infra,  p.  63),  and  by  fluoros- 
copy. The  true  position  of  the  cardiac  apex  thus  determined  corres- 
ponds usually  not  with  the  maximum  impulse,  but  with  the  point 
farthest  out  and  farthest  down  at  which  any  rise  and  fall  synchronous 
with  the  heart  beat  can  he  felt  (for  further  discussion  of  this  point  see 
below,  p.  256). 

(c)    Besides  the  definite  and  localized  impulse  which  has  just  been 
described,  it  is  often  possible  to  see  that  a  considerable  section  of  the 


INSPECTION 


81 


chest  wall  in  the  precordial  region  is  lifted  "  en  masse."  The  phenome- 
non is  the  "  Herzenstoss  "  of  the  Germans,  with  which  the  "  Spitzenstoss  " 
or  apex  impulse  is  contrasted.  A  variable  amount  of  "Herzenstoss" 
can  be  seen  and  felt  over  any  normal  heart  when  it  is  acting  rapidly  and 
forcibly,  and  in  thin,  nervous  subjects  or  in  children  even  when  the 
heart  is  beating  quietly.  It  is  more  marked  in  cardiac  neuroses  or  in 
cases  in  which  the  heart  is  hypertrophied  and  in  which  there  is  more 
or  less  stiffening  of  the  ribs  with  loss  of  their  natural  elasticity.     At 


Fig.  So. — The  Inner  Dot  is  the  Maximum  Cardiac  Impulse.     That  to  the  right  is  the  true 
apex  of  the  heart,  as  obtained  by  percussion.     The  ribs  are  numbered. 


times  it  may  be  impossible  to  localize  any  one  point  to  which  we  can 
give  the  name  of  apex  impulse,  and  what  we  see  is  the  rhythmical 
rise  and  fall  of  a  section  of  the  chest  as  large  as  the  palm  of  the  hand  or 
larger. 

(d)  Character  of  the  cardiac  impulse. — ^Palpation  is  considerably 
more  effective  than  inspection  in  giving  us  information  as  to  the  nature 
of  the  cardiac  movements  which  give  rise  to  the  "apex  beat,"  but 
even  inspection  sometimes  suffices  to  show  that  the  impulse  has  the 
slow  forcible  thrust  characteristic  of  hypertrophy  or  is  of  the  nature 
of  a  short  tap,  a  peristaltic  wave,  or  a  diffuse  slap  against  the  chest 
wall.     In  some  cases  a  distinct  undulation  can  be  seen  passing  from 

6 


82  PHYSICAL  DIAGNOSIS 

the  apex  region  upward  toward  the  base  of  the  heart,  or  less  often  in 
the  opposite  direction. 

(2)   Displacement  of  the  Cardiac  Impulse. 

To  one  famihar  with  the  position,  extent,  and  character  of  the 
normal  cardiac  impulse,  any  displacement  of  this  impulse  from  its 
normal  site  or  any  superadded  pulsation  in  another  part  of  the  chest 
is  apparent  at  a  glance.  I  will  consider  first  the  commonest  forms  of 
dislocation  of  the  apex  impulse. 

(a)  Displacement  of  the  cardiac  impulse  due  to  hypertrophy  and 
dilatation  of  the  heart. — By  far  the  most  common  directions  of  dis- 
placement are  toward  the  left  axilla,  or  downward.  As  a  rule,  it  is 
displaced  in  both  these  directions  at  once.  I  shall  return  to  this 
subject  more  in  detail  under  the  heading  Cardiac  Hypertrophy,  but 
here  I  may  say  that  enlargements  of  the  left  ventricle  tend  especially 
to  displace  the  apex  impulse  downward,  while  enlargements  of  the 
right  ventricle  are  more  commonly  associated  with  displacement  of 
the  impulse  toward  the  axilla. 

(6)  Next  to  hypertrophy  and  dilatation  of  the  heart  perhaps  the 
commonest  cause  of  dislocation  of  the  cardiac  impulse  is  pressure  from 
below  the  diaphragm.  When  the  diaphragm  is  raised  by  a  large 
accumulation  of  gas  or  fluid  or  by  solid  tumors  of  large  size,  we  may 
see  the  apex  beat  of  the  normal  heart  in  the  fourth  interspace  and 
often  an  inch  or  more  inside  the  nipple  line. 

(c)  Of  nearly  equal  frequency  is  displacement  of  the  heart  due  to 
pleuritic  effusion  or  to  pneumothorax  (see  below,  p.  313). 

When  a  considerable  amount  of  air  or  fluid  accumulates  in  the  left 
pleural  cavity,  the  heart  is  displaced  bodily  to  the  right  so  that  it 
may  be  concealed  behind  the  sternum  or  be  visible  beyond  it  to  the 
right;  in  extreme  cases  it  may  be  dislocated  as  far  as  the  right  nipple. 
Right  pleuritic  effusions  have  far  less  effect  upon  the  position  of  the 
cardiac  impulse,  but  when  a  very  large  amount  of  fluid  accumulates 
we  may  see  the  impulse  displaced  considerably  toward  the  left  axilla. 

{d)  I  have  mentioned  causes  tending  to  push  the  heart  to  the 
right,  to  the  left,  or  upward.  Occasionally  the  heart  is  pushed  down- 
ward by  an  aneurismal  tumor  or  a  neoplasm  of  the  mediastinum.  In 
these  cases  there  is  usually  more  or  less  displacement  to  the  left  as 
well.  As  a  result  of  arteriosclerosis  or  cardiac  hypertrophy  the  aorta 
may  sag  or  stretch  a  little,  the  diaphragm  may  stand  lower,  so  that 
the  apex  beat  descends  to  the  sixth  interspace,  or  (more  often)  is  lost  to 


INSPECTION  83 

sight  and  touch  behind  the  hunch  of  convergent  costal  cartilages  just  to 
the  left  of  the  ensiform.  Very  frequently  in  men  past  forty-five  the 
whole  heart  sinks  considerably,  so  that  a  marked  systolic  retraction 
(less  often  pulsation)  is  seen  below  the  ensiform  in  the  epigastrium. 

(e)  Displacement  of  the  cardiac  impulse  resulting  from  adhesions 
of  the  pericardium  to  the  pleura,  with  subsequent  contraction,  occurs 
in  fibroid  phthisis  and  in  some  cases  of  long-standing  disease  of  the 
pleura.  Through  the  effect  of  negative  pressure  the  heart  may  be 
sucked  into  the  space  formerly  occupied  by  a  portion  of  the  lung, 
when  the  latter  has  become  contracted  by  disease.  It  seems  likely, 
however,  that  in  the  majority  of  cases  adhesions  between  the  pleura 
and  pericardium  play  a  part  in  such  displacement.  By  these  means 
the  heart  may  be  displaced  to  the  right  of  the  sternum,  as  it  is  by  left- 
sided  pleuritic  effusion.  It  is  often  drawn  upward  as  well  as  to  the 
right  in  such  cases  because  the  contraction  takes  place  in  the  upper 
part  of  the  lung.  More  rarely  we  see  the  heart  drawn  toward  the 
left  clavicle  in  fibroid  phthisis  of  the  left  apex. 

(/)  Distortion  of  the  thorax  due  to  spinal  curvature  or  other  causes 
may  bring  about  a  considerable  displacement  of  the  heart  from  its 
normal  position. 

(g)  Dextrocardia  and  Situs  Inversus. — In  rare  cases  a  displacement 
of  the  apex  impulse  to  the  right  of  the  sternum  may  be  due  either  to  a 
transpositio7i  of  all  viscera  (the  liver  being  found  upon  the  left,  the 
spleen  upon  the  right,  etc.),  or  to  dextrocardia,  in  which  the  heart  alone 
is  transposed  while  the  other  viscera  retain  their  normal  places. 

Summary. 

The  apex  impulse  is  displaced  by: 

(a)  Hypertrophy  and  dilatation  of  the  heart, 

(b)  Pressure  from  below  the  diaphragm. 

(c)  Air  or  fluid  in  one  pleural  cavity,  especially  the  left. 

(d)  Aneurism,  mediastinal  growths,  and  sagging  of  the  aorta. 

(e)  Fibroid  phthisis  and  chronic  pleurisy. 
(/)   Spinal  curvature. 

(g)   Transposition  of  the  heart  or  of  all  the  viscera. 

(3)   Apex  Retraction. 

Before  leaving  the  subject  of  the  cardiac  impulse  it  seems  best  to 
speak  of  those  cases  in  which  during  systole  we  see  a  retraction  of  one 
or  more  interspaces  at  or  near  the  point  where  the  cardiac  impulse 
normally  appears. 


84  ■        PHYSICAL  DIAGNOSIS 

(a)  In  by  far  the  greater  number  of  instances  such  retraction  is 
due  to  negative  pressure  produced  within  the  chest  by  the  vigorous 
contraction  of  a  more  or  less  hypertrophied  and  dilated  heart.  In 
these  cases  the  retraction  is  usually  balanced  by  an  impulse  in  the 
next  interspace  so  that  a  "walking  beam"  appearance  or  tilting  of  a 
piece  of  the  chest  wall  results. 

(6)  In  rarer  cases  several  interspaces,  both  in  the  precordial 
region  and  in  the  left  lower  axilla  and  back,  may  be  drawn  in  as  a 
result  of  adhesions  between  the  pericardium  and  the  chest  wall,  such 
as  form  in  cases  of  adherent  pericardium  and  fibrous  mediastinitis^ 
(see  below,  pages  260  and  262.) 

(4)   Epigastric  Pulsation. 

In  a  considerable  portion  of  healthy  adults  a  pulsation  or  retrac- 
tion at  the  epigastrium  synchronous  with  the  systole  of  the  heart  is  to 
be  seen  from  time  to  time.  Such  pulsation  has  often  been  considered 
evidence  of  hypertrophy  of  the  right  ventricle,  but  autopsy  findings 
do  not  substantiate  this  belief.  In  some  cases  epigastric  pulsation  is 
to  be  explained  as  the  transmission  of  the  heart's  impulse  through  the 
liver,  or  as  a  lifting  of  that  organ  by  the  movements  of  the  abdominal 
aorta.  In  other  cases  it  is  due  to  bathycardia  ("low  heart" — a  con- 
dition very  common  in  arteriosclerosis). 

(5)    Visible    Pulsations  due   to    Uncovering   of  Portions   of  the   Heart 
Normally  Covered  by  the  Lungs. 

One  of  the  commonest  causes  of  visible  pulsations  in  parts  of  the 
chest  where  normally  none  is  to  be  seen  is  retraction  of  the  lung. 

(a)  It  is  in  chlorosis,  perhaps,  that  we  most  frequently  see  such 
pulsations.  In  that  disease,  as  in  other  debilitated  states,  the  lungs 
are  often  not  adequately  expanded  owing  to  the  superficiality  of  the 
respiration,  and  accordingly  their  margins  do  not  cover  as  much  of  the 
surface  of  the  heart  as  they  do  in  healthy  adults.  This  results  in 
rendering  visible,  in  the  second,  third,  or  fourth  left  interspace  near 
the  sternum,  pulsations  transmitted  from  the  conus  arteriosus  or  from 
the  right  ventricle.  Less  commonly,  similar  pulsations  due  to  the 
uncovered  aorta  may  be  seen  on  the  right  side  of  the  sternum. 

(b)  A  rarer  cause  of  retraction  of  the  lungs  is  fibroid  phthisis  or 
chronic  interstitial  pneumonia.     In  these  diseases  a  very  large  area  of 

^  Or  more  often  as  a  result  of  simple  cardiac  hypertrophy.     More  cases  of  aortic 
regurgitation  in  thin  young  patients  show  this  systolic  retraction  in  the  left  lower  back. 


INSPECTION 


85 


pulsation  may  be  seen  in  the  precordial  region  owing  to  the  entire  un- 
covering of  the  heart  by  the  retracted  lung,  even  when  the  heart  is  not 
drawn  out  of  its  normal  position. 

VIII.  Aneurism,  Dilated  Aorta,  and  Other  Causes  of  Abnormal 
Thoracic  Pulsation. 

So  far  I  have  spoken  altogether  of  pulsations  transmitted  directly 
to  the  thorax  by  the  heart  itself,  but  we  have  also  to  bear  in  mind  that 
an  aneurism  or  a  dilated  aorta  may  transmit  to  the  chest  wall  pulsa- 
tions which  it  is  exceedingly  important  for  us  to  recognize  and  properly 
to  interpret.  No  disease  is  easier  to  recognize  than  aneurism  when  the 
growth  has  perforated  the  chest  wall  and  appears  as  a  tumor  externally, 
but  it  is  much  more  important  as  well  as  much  more  difficult  to  recog- 
nize the  disease  while  it  is  confined  within  the  thorax.     In  such  cases. 


Fig.  8i. — Position  When  Looking  for  Slight  Aneurismal  Pulsation. 


the  movements  transmitted  from  the  aorta  to  the  chest  wall  may  be 
so  slight  that  only  the  keenest  and  most  thorough  inspection  controlled 
by  palpation  will  detect  them.  When  slight  pulsations  are  searched 
for,  the  patient  should  be  put  in  the  position  shown  in  Fig.  8i,  and  the 
observer  should  place  himself  so  that  his  eye  is  as  nearly  as  possible  on 
a  level  with  the  chest  and  looks  across  it  so  that  he  sees  it  in  profile. 
In  this  position,  or  in  a  sitting  position  with  tangential  light,  he  can 
make  out  pulsations  which  are  totally  invisible  if  the  patient  sits 
facing  the  light.  ; 


86  PHYSICAL  DIAGNOSIS 

Pulsations  due  to  a  dilated  aorta  or  to  aneurism  are  most  apt  to 
be  seen  in  the  first  or  second  right  interspace  near  the  sternum,  and 
not  infrequently  the  clavicle  and  the  adjacent  parts  may  be  seen  to 
rise  slightly  with  every  beat  of  the  heart,  but  in  any  part  of  the  chest 
wall  pulsations  due  to  an  aneurism  are  occasionally  to  be  seen,  and 
should  be  looked  for  scrupulously  whenever  the  symptoms  of  the  case 
suggest  the  possibility  of  this  disease  (see  below,  p.  264). 

Pulsating  Pleurisy. 

In  cases  of  purulent  pleurisy  in  which  the  fluid  has  worked  its  way 
out  between  the  ribs  so  that  it  is  covered  only  by  the  skin  and  sub- 
cutaneous tissues,  a  pulsation  transmitted  from  the  heart  may  become 
visible,  and  the  resemblance  to  the  pulsation  seen  in  aneurism  may  be 
confusing.  Such  pulsation  is  apt  to  be  seen  in  the  upper  and  front 
portions  of  the  chest.  Very  rarely  a  pleuritic  effusion  which  has  not 
burrowed  into  the  chest  wall  may  transmit  to  the  latter  a  wavy  move- 
ment corresponding  to  the  motions  set  up  in  the  fluid  by  the  cardiac 
contractions. 

IX.  Inspection  of  the  Peripheral  Vessels. 

In  the  study  of  all  diseases  of  the  heart  and  lungs  it  is  important 
to  take  account  of  all  vascular  phenomena  apparent  in  the  neck  or  in 
the  extremities,  since  such  phenomena  have  a  very  direct  bearing  upon 
the  interpretation  of  the  conditions  obtaining  within  the  chest.  In- 
spection plays  a  very  large  part  in  the  study  of  these  vascular  phe- 
nomena. We  should  look  for:  (a)  Venous  phenomena;  (&)  Arterial 
phenomena;  (c)  Capillary  phenomena. 

(a)   Inspection  of  the  Veins. 

I .  The  condition  of  the  veins  of  the  neck  is  of  considerable  impor- 
tance in  the  diagnosis  of  diseases  of  the  heart  and  lungs.  Where  the 
tissues  of  the  neck  are  more  or  less  wasted  the  veins  may  be  quite 
prominent  even  when  no  disease  exists  within  the  chest,  and  in  such 
cases  they  may  be  more  or  less  distended  during  each  expiration, 
especially  if  dyspnoea  or  cough  is  present.  If  the  overdistended  veins 
are  completely  emptied  during  deep  inspiration  and  on  both  sides  of 
the  neck,  we  can  usually  infer  that  there  is  an  overdistention  of  the 
right  side  of  the  heart.  When  a  similar  phenomenon  occurs  on  one 
side  only,  it  may  mean  pressure  upon  one  innominate  vein.  So  far  I 
have  spoken  of  venous  changes  synchronous  with  respiration,  but  we 
may  have  also 


INSPECTION 


87 


2.  A  presystolic  pulsation  or  undulation  seen  either  in  the  external 
jugular  vein  or  in  the  bulbus  jugularis  between  the  two  attachments 
of  the  sternomastoid  muscles.  Such  pulsation  or  undulation,  which 
is  to  be  seen  just  before  each  systole  of  the  heart,  is  not  necessarily 
anything  abnormal  and  must  be  carefully  distinguished  from 

3.  Systolic  venous  pulsation,  such  as  occurs  in  one  of  the  most 
common    valvular    diseases    of   the    heart — tricuspid   regurgitation,^ 


Fig.  82. — Tortuous  Veins  on  Chest  and  Abdomen.     (Autopsy  showed  obliteration  of  the 

vena  cava  inferior.) 


as  well  as  in  a  good  many  other  conditions.  Systolic  venous  pulsation 
is  more  often  seen  upon  the  right  side  than  upon  the  left  side  of  the 
neck.  There  may  be  a  wave  during  the  systole  of  the  auricle  and 
another  during  the  systole  of  the  ventricle,  the  latter  closely  following 
the  former.  In  any  case  in  which  a  doubt  arises  whether  a  pulsation 
in  the  veins  of  the  neck  is  due  to  tricuspid  regurgitation,  it  is  well  to 

^  A  pulsating  carotid  may  transmit  an  up-and-down  motion  to  the  veins  overlying 
it.  In  such  cases,  if  the  veins  be  emptied  by  "milking"  them  upward,  they  will  not 
refill  from  below. 


88  PHYSICAL  DIAGNOSIS 

try  the  experiment  of  emptying  the  vein  by  stroking  it  from  below 
upward.  If  it  immediately  fills  from  below,  we  may  be  practically 
certain  that  tricuspid  regurgitation  is  present.  In  the  vast  majority 
of  cases  of  venous  pulsation  due  to  other  causes  or  occurring  in  healthy 
persons  a  vein  will  not  refill  from  below  if  emptied  in  the  manner  above 
described.  The  finer  points  relating  to  the  variations  in  the  cervical 
venous  pressure  are  recognized  by  phlebograms  traced  by  MacKenzie's 
instrument  or  in  some  similar  way. 

The  venous  waves  so  recorded  tell  us  much  that  is  interesting 
and  some  things  that  are  important  about  the  behavior  of  the  auricles. 
(See  below,  p.  114.) 


Fig.  83. — Enlarged  Tortuous  Brachial  Arteries  (Arterio-sclerosis) . 

4.  Rarely,  superficial  veins  may  be  seen  to  pulsate  in  other  parts 
of  the  body,  especially  in  aortic  regurgitation,  and  occasionally  large 
and  tortuous  veins  may  be  seen  pulsating  upon  the  thoracic  or  abdom- 
inal wall,  representing  an  attempt  at  collateral  circulation  when  one 
or  the  other  vena  cava  is  compressed  (Fig.  83)."^ 

(6)   Arterial  Phenomena. 

I .  In  thin  or  nervous  persons  pulsations  are  not  infrequently  to  be 
seen  in  the  carotids  independent  of  any  abnormal  condition  of  the 
heart. 

^  Enlarged  veins  about  the  navel,  the  so-called  "caput  Medusae,"  are  commonly  found 
in  text-books,  but  rarely  in  cirrhosis  of  the  liver. 


INSPECTION  *  89 

2.  Very  violent  throbbing  of  the  carotids,  more  noticeable  than 
the  normal,  often  occurs  in  severe  anaemias  and  occasionally  in  simple 
hypertrophy  of  the  heart  without  any  valvular  disease.  From  the 
same  causes,  visible  pulsation  may  occur  in  the  subclavian,  axillary, 
brachial,  and  radial  arteries,  as  well  as  in  the  large  arterial  trunks  of 
the  lower  extremity. 

I  lately  examined  a  blacksmith  whose  heart  was  considerably 
enlarged  by  hard  work,  but  without  any  valvular  disease.  Pulsation 
was  violent  in  all  the  peripheral  arteries  which  I  have  just  named. 

3.  In  arterio-sclerosis  occurring  in  spare,  elderly  men,  with  or 
without  aortic  regurgitation,  one  often  notices  a  lateral  excursion  of 


-^ 


Fig.  84. — Enlarged  and  Tortuous  Brachial  Artery  (Arterio-sclerosis). 


the  tortuous  brachial  arteries  synchronous  with  every  heart  beat. 
An  up-and-down  pulsation  may  occur  at  the  same  time.  Not  infre- 
quently the  arteries  which  are  stiffened  by  deposition  of  lime  salts 
(see  below,  page  105)  stand  out  visibly  as  enlarged,  tortuous  cords 
upon  the  temple  and  along  the  inner  sides  of  the  biceps  muscle,  (see 
Figs.  83  and  84)  and  occasionally  the  course  of  the  radial  artery  may 
be  traced  over  a  considerable  distance  in  the  forearm.  In  rare  cases 
inequalities  produced  in  the  arterial  wall  by  deposition  of  lime  salts 
may  be  visible  as  well  as  palpable. 


90  PHYSICAL  DIAGNOSIS 

(c)    Capillary  Pulsation. 

If  a  microscopic  slide  is  placed  against  the  mucous  membrane  of 
the  lower  lip  so  as  partially  to  blanch  its  surface,  one  may  see,  with 
each  beat  of  the  heart  (in  cases  of  aortic  regurgitation  and  in  some 
other  conditions  present!}'  to  be  mentioned) ,  a  delicate  flushing  of  the 
blanched  surface  beneath  the  glass  slide.  The  same  pulsation  is 
sometimes  to  be  obser\'ed  under  the  finger  nails,  or  may  be  still  better 
brought  out  b}'  drawing  a  pencil  or  other  hard  substance  across  the 
forehead  so  as  to  cause  a  line  of  h^^persmia,  at  the  edge  of  which  the 
systolic  flushing  occurs.  This  phenomenon  will  be  referred  to  again 
when  we  come  to  speak  of  aortic  regurgitation.  Here  it  suffices  to 
say  that  it  is  not  in  any  way  peculiar  to  that  disease,  and  occurs 
occasionally  in  health,  in  anaemia,  in  exophthalmic  goitre,  and  in 
conditions  associated  with  low  tension  in  the  peripheral  arteries,  as 
well  as  in  any  area  of  inflammatory-  hypersemia  (jumping  toothache, 
throbbing  felon,  etc.). 

X.  Inspection  of  the  Skin  and  Mucous  Membranes. 

Light  may  be  thrown  upon  the  diagnosis  of  ver}'  many  diseases 
by  observing  the  color  and  condition  of  the  cutaneous  surfaces  as  well 
as  of  the  mucous  membranes.  We  should  look  for  the  following 
conditions : 

(i)   Cyanosis. 

(2)  CEdema. 

(3)  Pallor. 

(4)  Jaundice. 

(5)  Scars  and  eruptions. 

(i)    Cyanosis. 

By  cyanosis  we  mean  a  purplish  or  grayish-blue  tint  noticeable 
especiall}^  in  the  face,  in  the  lips,  and  under  the  nails.  There  are 
many  degrees  of  cyanosis,  from  the  slight  purplish  tinge  of  the  lips, 
which  a  little  overexertion  or  slight  exposure  to  cold  may  bring  out, 
up  to  the  gray-blue  color  seen  in  advanced  cases  of  pulmonary  or 
cardiac  disease,  or  the  dark  reddish-blue  seen  in  congenital  malforma- 
tions of  the  heart.  Cyanosis  makes  a  very  different  impression  upon 
us  when  it  is  combined  with  pallor  on  the  one  hand  or  with  jaundice  on 
the  other.  When  combined  with  pallor,  one  gets  various  ashy-gray 
tints,  while  the  admixture  of  cvanosis  and  jaundice  results  in  a  color 


INSPECTION  91 

very  difficult  to  describe,  sometimes  approaching  a  greenish  hue.     The 
commonest  causes  of  cyanosis  are: 

(a)  Valvular  or  parietal  disease  of  the  heart. 

(b)  Emphysema. 

(c)  Asthma. 

(d)  Pneumonia. 

(e)  Phthisis. 

(/)  Obstruction  of  the  superior  vena  cava  by  mediastinal  tumors 
or  other  causes. 

(g)  In  some  persons  a  certain  degree  of  cyanosis  of  the  lips  exists 
despite  perfect  health.  This  is  especially  true  of  weather-beaten 
faces  and  those  of  the  so-called  "full-blooded"  type. 

(h)  Methaemoglobinaemia,  such  as  occurs  after  the  excessive  use 
of  coal-tar  analgesics  (antifebrine,  etc.). 

A  rare  but  very  striking  type  of  cyanosis  is  that  seen  in  cases 
of  congenital  heart  disease,  in  which  the  lips  may  be  indigo  blue  in 
color  or  almost  black  while  yet  no  dyspnoea  is  present. 

Cyanosis  of  intestinal  origin  has  been  described  by  English  writers. 
It  is  distinctly  rare. 

In  polycythsemia  the  face  and  lips  may  show  the  ordinary  tint 
of  cyanosis  or  may  be  of  a  deep  red  peculiar  to  this  disease. 


(2)  (Edema. 

CEdema,  or  the  accumulation  of  serous  fluid  in  the  subcutaneous 
spaces,  is  usually  appreciated  by  palpation  rather  than  by  inspec- 
tion, but  sometimes  makes  the  face  look  very  puffy,  especially  under 
the  eyes.  This  is  not  a  common  occurrence  in  diseases  of  the  chest, 
in  connection  with  which  such  oedema  as  takes  place  is  usually  to 
be  found  in  the  lower  extremities  and  is  appreciable  rather  by  palpa- 
tion than  by  inspection.  If  we  are  not  familiar  with  a  patient's  face, 
we  often  do  not  perceive  in  it  the  changes  of  outline  due  to  oedema 
which  a  friend  would  notice  at  once.  Clothing  is  apt  to  leave  grooves 
and  marks  wherever  it  presses  tightly  upon  the  oedematous  tissues, 
as  around  the  waist  or  over  the  shoulders.  In  the  legs,  the  presence 
of  oedema  may  be  suggested  by  an  unnaturally  smooth,  glossy  appear- 
ance of  the  skin.  Such  impressions,  however,  may  be  false  unless 
controlled  by  palpation,  for  simple  obesity  may  produce  very  similar 
appearances. 


92  PHYSICAL  DIAGNOSIS 

(3)  Pallor. 

Pallor  suggests,  though  it  does  not  in  any  way  prove,  anaemia. 
Pallor  of  the  mucous  membranes,  as  seen  in  the  lips  and  conjunctivae, 
is  much  more  apt  to  be  a  sign  of  real  anaemia  than  is  pallor  of  the 
skin.  At  best,  pallor  is  only  a  sign  which  suggests  to  us  to  look 
further  into  the  case  in  one  or  another  direction,  and  of  itself  proves 
nothing  of  importance.  Haemorrhage,  cancer,  nephritis,  septicaemia 
and  pernicious  anaemia  are  the  commonest  causes  of  anaemia.  Pallor 
without  anaemia  is  often  seen  in  tuberculosis,  in  arteriosclerosis  and 
in  the  psychoneuroses. 

(4)  Jaundice. 

The  yellowish  tint  which  appears  in  the  skin,  and  especially  in 
the  conjunctivae,  when  the  escape  of  bile  from  the  liver  is  hindered 
(catarrhal  jaundice,  gall-stones,  cancer,  cirrhosis),  or  when  rapid 
hemolysis  has  occurred  (malaria  sepsis). 

(5)  Scars  and  Eruptions. 

The  scars  of  old  tuberculous  glands  in  the  neck,  the  scars  of 
varicose  ulcers  along  the  shin  bones,  the  various  scars  and  eruptions 
of  syphilis,  of  the  exanthemata  and  of  trauma  and  of  surgical  opera- 
tions are  of  value  in  tracing  the  past  history  and  interpreting  the 
present  illness.  Without  attempting  to  enter  the  field  of  dermatology 
it  may  be  here  mentioned  that  for  the  internist  the  skin  lesions  most 
important  of  recognition  are  those  just  mentioned  and,  in  addition, 
drug  eruptions,  cutaneous  neoplasms  and  the  various  causes  of 
pigmentation. 

XL  Enlarged  Glands. 

Routine  inspection  may  reveal  the  presence  of  enlarged  glands  in 
the  neck  or  axillae  or  groins,  and  may  thereby  give  us  a  clew  to  the 
nature  of  the  underlying  disease;  for  example,  the  presence  of  enlarged 
glands  in  the  neck,  especially  if  there  are  any  scars,  sinuses,  or  other 
evidence  that  suppuration  is  going  on  or  has  formerly  taken  place 
in  them,  suggests  the  possibility  of  pulmonary  tuberculosis  or  of  an 
enlargement  of  the  bronchial  and  mediastinal  glands.  In  children 
cervical  adenitis  is  most  often  a  sign  of  bad  teeth,  tonsillitis  and 
head  lice.     Again,  malignant  disease  of  the  chest  or  abdomen  is  some- 


INSPECTION 


93 


times  associated  with  the  metastatic  nodules  over  the  clavicle  (see 
Fig.  85),  and  a  microscopic  examination  of  them  may  thus  reveal 
the  nature  of  the  intrathoracic  disease  to  which  they  are  secondary. 
Very  large  and  matted  masses  of  glands  above  the  clavicle,  which 
have  never  suppurated  and  have  been  painless  and  slow  in  their 
growth,  suggest  the  presence  of  similar  deposits  in  the  mediastinum 
as  a  part  of  the  symptom  complex  known  as  "Hodgkin's  disease." 
The  presence  of  a  goitre  or  enlargement  of  the  thyroid  gland  may 


Fig.  85. — Sarcoma  of  Sternum  and  Cervical  Glands.     (Curschmann.) 


account  for  a  well-marked  dyspnoea.  Axillary  adenitis  means  most 
often  peripheral  sepsis,  next  tuberculosis,  then  metastatic  cancer, 
leucaemia  and  Hodgkin's  disease.  Inguinal  adenitis  (suppurative)  is 
most  often  a  result  of  gonorrhoea.  If  non-suppurative,  it  is  usually 
due  to  sepsis  in  the  leg,  syphilis,  leucaemia  and  Hodgkin's  disease 
and  metastatic  cancer. 

Syphilis  produces  general  glandular  enlargement;  the  posterior 
cervical  and  the  epitrochlear  glands  are  often  involved,  but  this  is 
also  the  case  in  many  diseases  other  than  syphilis. 


CHAPTER  V. 
PALPATION  AND  THE  STUDY  OF  THE  PULSE. 

I.  Palpation. 

The  most  important  points  to  be  determined  by  palpation — ^that 
is,  by  laying  the  hand  upon  the  surface  of  the  chest — are : 

(i)   The  position  and  character  of  the  apex  heat  of  the  heart. 

(2)  The  presence  of  a  ''thrill"  (see  below). 

(3)  The  vibrations  of  the  spoken  voice  {^'  tactile  fremitus") . 

(4)  The  presence  of  pleuritic  or  pericardial /ric^-iow. 

Other  less  important  data  furnished  by  palpation  will  be  mentioned 
later. 

(i)    The  Apex  Beat. 

(a)  In  feeling  for  the  apex  impulse  of  the  heart,  one  should 
first  lay  the  palm  of  the  hand  lightly  upon  the  chest  just  below  the 
left  nipple.  In  this  way  we  can  appreciate  a  good  deal  about  the 
movements  of  the  heart,  and  confirm  or  modify  what  we  have  learned 
by  inspection.  One  learns,  in  the  first  place,  whether  the  heart  beat 
is  regular  or  not,  and  in  case  it  is  irregular,  whether  the  beats  are 
unequal  in  force  or  whether  some  are  skipped;  further,  one  gets  a 
more  accurate  idea  than  can  be  obtained  through  inspection  regarding 
the  character  of  the  cardiac  movements.  The  powerful,  slow,  widespread 
impulse  of  a  hypertrophied  heart,  the  diffuse  slap  often  felt  in 
dilatation  of  the  right  ventricle,  the  sudden  tap  characteristic  of 
mitral  stenosis,  may  be  thus  appreciated. 

(6)  After  this,  it  is  best  to  lay  the  tips  of  two  or  three  fingers 
over  the  point  where  the  maximum  impulse  is  to  be  seen,  and  follow 
it  outward  and  downward  until  one  arrives  at  the  point  farthest 
to  the  left  and  farthest  down  at  which  it  is  still  possible  to  feel 
any  up-and-down  movement.  The  point  usually  corresponds  with 
the  apex  of  the  heart,  as  determined  by  percussion  or  fluoroscopy. 
It  does  not  correspond  with  the  maximum  cardiac  impulse,  but  is  often 
to  be  found  at  least  an  inch  farther  to  the  left  and  downward  (see 
above,  Fig.  80). 

94 


PALPATION  AND  THE  STUDY  OF  THE  PULSE  95 

Sometimes  one  can  localize  by  palpation  a  cardiac  impulse  which 
is  not  visible;  on  the  other  hand,  in  some  cases  we  can  see  pulsations 
that  we  cannot  feel.      Both  methods  must  be  used  in  every  case. 

The  results  obtained  by  palpation  and  inspection  of  the  apex 
region  give  us  the  most  reliable  data  that  we  have  regarding  the  size 
of  the  heart.  Percussion  may  be  interfered  with  by  the  presence 
of  gas  in  the  stomach,  of  fluid  or  adhesions  in  the  pleural  cavity,  or 
by  the  ineptness  of  the  observer,  but  it  is  almost  always  possible 
with  a  little  care  to  make  out  by  a  combination  of  palpation  and 
inspection  the  position  of  the  apex  of  the  heart.  When  we  can  neither 
feel  it  nor  see  it,  we  may  have  to  fall  back  upon  auscultation,  consider- 
ing the  apex  of  the  heart  to  be  at  or  near  the  point  at  which  the  heart 
sounds  are  heard  loudest.  When  endeavoring  to  find  the  apex  of 
the  heart,  we  must  not  forget  that  the  position  of  the  patient  influ- 
ences considerably  the  relation  of  the  heart  to  the  chest  walls.  If 
the  patient  is  leaning  toward  the  left  or  lying  on  the  left  side,  the 
apex  will  swing  out  several  centimetres  toward  the  left  axilla.  If 
the  peripheral  blood  pressure  is  permanently  high,  it  is  well  to  conclude 
that  the  heart  is  enlarged,  whatever  the  other  physical  signs. 

(2)  "  Thrills." 

When  feeling  for  the  cardiac  impulse  with  the  palm  of  the  hand, 
we  are  in  a  good  position  to  notice  the  presence  or  absence  of  a  very 
important  physical  sign  to  which  we  give  the  name  of  ''thrill."  The 
feeling  imparted  to  the  fingers  by  the  throat  of  a  purring  cat  is  very 
much  like  the  palpable  ' '  thrill' '  over  the  precordia  in  certain  diseases 
of  the  heart  to  be  mentioned  later.  It  is  a  vibration  of  the  chest 
wall,  usually  confined  to  a  small  area  in  the  region  of  the  apex  impulse, 
but  sometimes  felt  in  the  second  right  intercostal  space  or  elsewhere 
in  the  precordial  region.  This  vibration  or  thrill  almost  always 
occurs  intermittently,  i.e.,  only  during  a  portion  of  the  cardiac  cycle. 
When  felt  in  the  apex  region,  it  usually  occurs  just  before  the  cardiac 
impulse;  this  fact  we  express  by  calling  it  a  "presystolic  thrill";  but 
occasionally  we  may  feel  a  systolic  thrill  at  the  apex — one,  that  is, 
which  accompanies  the  cardiac  impulse.  The  word  thrill  should  be 
used  to  denote  only  a  purring,  vibrating  sensation  communicated  to 
the  fingers  by  the  chest  wall.  It  is  incorrect  to  speak  of  a  thrill  as 
if  it  were  something  audible. 

We  must  also  distinguish  a  purring  thrill  from  the  slight  shudder 
or  jarring  which  often  accompanies  the  cardiac  impulse  in  functional 
neuroses  of  the  heart  or  in  conditions  of  mental  excitement. 


96 


PHYSICAL  DIAGNOSIS 


As  a  rule  we  can  appreciate  a  thrill  more  easily  if  we  lay  the  palm 
very  lightly  upon  the  chest,  using  as  little  pressure  as  possible.  Firm 
pressure  may  prevent  the  occurrence  of  the  vibrations  which  we 
desire  to  investigate.  Of  the  thrills  felt  over  the  base  of  the  heart, 
more  will  be  said  in  Chapter  X. 


(3)  Vibrations  Communicated  to  the  Chest  Wall  by  the  Voice. 

"Tactile  fremitus''  is  the  name  given  to  the  sense  of  vibration 
communicated  to  the  hand  if  the  latter  is  laid  upon  the  chest  while 
the  patient  repeats  some  short  phrase  of  words.  The  classical  method 
of  testing  tactile  fremitus  is  to  ask  the  patient  to  count  "one,  two, 
three,"  or  to  repeat  the  words  "ninety-nine"  while  the  palm  of  the 
hand  is  laid  flat  upon  the  chest.  The  amount  of  fremitus  to  be  ob- 
tained over  a  given  part  of  the  thorax  varies,  of  course,  according 
to  the  loudness  of  the  words  spoken,  and  is  influenced  also  by  the 
vowels  contained  in  them.     A  certain  uniformity  is  obtained  by  getting 

the  patient  to  repeat  always  the 
same  formula.  Thus,  he  is  likely 
to  use  the  same  amount  of  force 
each  time  he  repeats  them  and 
to  use  approximately  the  same 
pitch  of  voice. 

Other  things  being  equal,  the 
fremitus  is  greater  in  men  than 
in  women,  in  adults  than  in 
children,  and  is  more  marked  in 
those  whose  voices  are  low 
pitched  than  in  those  whose 
voices  are  relatively  shrill.  The 
amount  of  fremitus  also  varies 
widely  in  different  parts  of  the 
healthy  chest.  A  glance  at  Fig. 
86  will  help  us  to  realize  this.  The  parts  shaded  darkest  communi- 
cate to  the  fingers  the  most  marked  fremitus,  while  in  the  parts  not 
shaded  at  all,  little  or  no  fremitus  is  felt.  Intermediate  degrees  of 
vibration  are  represented  by  intermediate  tints  of  shading.  From 
this  diagram  we  see  at  once  {a)  that  the  maximum  of  fremitus  is 
to  be  obtained  over  the  apex  of  the  right  lung  in  front,  (&)  that  it  is 
greater  in  the  upper  part  of  the  chest  than  in  the  lower,  and  some- 
what greater  throughout  the  right  chest  than  in  corresponding  parts 


Fig.  86. — Distribution  of  Tactile  Fremitus 


PALPATION  AND  THE  STUDY  OF  THE  PULSE 


97 


of  the  left.      This  natural  inequality  of  the  two  sides  of  the  chest  cannot 
he  too  strongly  emphasized. 

Comparatively  little  fremitus  is  to  be  felt  over  the  scapulae  be- 
hind, and  still  less  in  the  precordial  region  in  front.  The  outlines 
of  the  lungs  can  be  quite  accurately  mapped  out  by  means  of  the 
tactile  fremitus  in  adults  of  low-pitched  voice.  In  children,  as  has 
been  already  mentioned,  fremitus  is  usually  very  slight  and  may  be 
entirely  absent,  and  in  many  women  it  is  too  slight  to  be  of  any 
considerable   diagnostic   value.     Again,    some   very  fat   persons   and 


Fig.  87. — Showing  Point  at  Which  Pleural  Friction  is  ISIost  Often  Heard. 


those  with  thick  chest  walls  transmit  but  little  vibration  to  their  chest 
walls  when  they  speak.  On  the  other  hand,  in  emaciated  patients 
or  in  those  with  thin-walled,  flexible  chests,  the  amount  of  fremitus 
is  relatively  great. 

Bearing  in  mind  all  these  disparities — disparities  both  between 
persons  of  different  age  and  different  sex,  and  between  the  two  sides 
of  the  chest  in  any  one  person — we  are  in  a  position  to  appreciate 


98 


PHYSICAL  DIAGNOSIS 


the  modifications  to  which  disease  gives  rise  and  which  may  be  of 
great  importance  in  diagnosis.     These  variations  are : 

(a)  Diminution  or  absence  of  fremitus. 

(&)  Increase  or  absence  of  fremitus. 

(a)  If  the  lung  is  pushed  away  from  the  chest  wall  by  the  presence  of 
air  or  fluid  or  tumor  (pneumothorax,  pleurisy,  hydro  thorax,  neoplasms) 
in  the  pleural  cavity,  we  get  a  diminution  or  absence  of  tactile  frem- 
itus— diminution  where  the  layer  of  fluid  or  air  is  very  thin,  absence 
where  it  is  of  considerable  thickness. 

(6)  Solidification  of  the  lung  due  to  phthisis  or  pneumonia  is  the 
commonest  cause  of  an  increase  in  tactile  fremitus.  Further  details 
as  to  the  variations  in  amount  of  fremitus  in  different  diseases  may 
be  found  in  later  chapters  of  this  book. 


(4)  Friction,  Pleural  or  Pericardial. 

In  many  cases  of  inflammatory  roughening  of  the  pleural  sur- 
faces ("dry  pleurisy"),  a  grating  or  rubbing  of  the  two  surfaces  upon 

each  other  may  be  felt  as  well 
as  heard  during  the  move- 
ments of  respiration,  and 
especially  at  the  end  of  in- 
spiration. Such  friction  is 
most  often  felt  at  the  bottom 
of  the  axilla,  on  one  side  or 
the  other,  where  the  dia- 
phragmatic pleura  is  in  close 
apposition  with  the  costal 
layer  (see  Fig.  87,  p.  97). 

Similarly,  in  roughening 
of  the  pericardial  surfaces 
("dry"  or  "plastic"  peri- 
carditis) it  is  occasionally 
possible  to  feel  a  grating  or 
rubbing  in  the  precordial  region  more  or  less  synchronous  with  the 
heart's  movements.  Such  friction  is  most  often  to  be  felt  in  the  region 
of  the  fourth  left  costal  cartilage  (see  Fig.  88). 

Palpable  friction  is  of  great  value  in  diagnosis  because  it  is  a  sign 
about  which  we  can  feel  no  doubt;  as  such  it  frequently  confirms  our 
judgment  in  cases  in  which  the  auscultatory  signs  are  less  clear.  Fric- 
tion   sounds   heard  with   the  stethoscope  may  be  closely  simulated 


Fig.   88.— Showing  Point   (P)    at  Which  Peri 
cardial  Friction  is  Most  Often  Heard. 


PALPATION  AND  THE  STUDY  OF  THE  PULSE 


99 


by  the  rubbing  of  the  stethoscope  upon  the  skin,  but  palpable  friction 
is  simulated  by  nothing  else,  unless  occasionally  by 

(5)  Palpable  Rales. 

Occasionally  low  pitched,  snoring  rales  communicate  a  sensation 
to  the  hand  placed  upon  the  chest  in  the  region  beneath  which  the 
rales  are  produced ;  to  the  practised  hand  this  sensation  is  quite  differ- 
ent from  that  produced  by  pleural  friction,  although  the  difference 
is  hard  to  describe. 


(6)   Tender  Points  upon  the  Thorax. 

In  mitral  disease,  dry  pleurisy,  necrosis  of  the  rib,  and  some- 
times in  phthisis,  one  finds  areas  of  marked  tenderness  in  different 
parts  of  the  chest.  In  mitral 
disease  it  is  the  parts  near  the 
apex  impulse  that  are  sore.  The 
position  of  the  tender  points  in 
intercostal  neuralgia  generally 
corresponds  with  the  point  of 
exit  of  the  intercostal  nerves. 
These  points  are  shown  in  Fig.  89. 

The  tenderness  in  phthisis  is 
most  apt  to  be  in  the  upper  and 
front  portions  of  the  chest.  In 
neurotic  individuals  we  some- 
times find  a  very  superficial 
tenderness  over  parts  of  the 
thorax;  in  such  cases  pain  is 
produced  by  very  light  pressure, 
but  not  by  firm  pressure  at  the  same  point. 

The  presence  of  pulsations  in  parts  of  the  chest  where  normally 
there  should  be  none  is  suggested  by  inspection  and  confirmed  by 
palpation.  It  is  not  necessary  to  repeat  what  was  said  above  as  to 
the  commonest  causes  of  such  abnormal  pulsations.  When  searching 
for  slight,  deep-seated  pulsation  {e.g.,  from  an  aortic  aneurism),  it  is  well 
to  use  bimanual  palpation,  keeping  one  hand  on  the  front  of  the  chest 
and  the  other  over  a  corresponding  area  in  the  back. 

Fluctuation  or  elasticity  in  any  tumor  or  projection  from  the 
chest  is  a  very  important  piece  of  information  which  palpation  may 
give  us. 


Fig. 


-Showing  Points  of  Exit  of  the 
Intercostal  Nerves. 


100  PHYSICAL  DIAGNOSIS 

The  temperature  and  quality  of  the  skin  are  often  brought 
to  our  attention  during  palpation.  After  a  little  practice  one  can 
usually  judge  the  temperature  within  a  degree  or  two  simply  from 
the  feeling  of  the  skin.  Any  roughness,  dryness,  or  loss  of  elas- 
ticity of  the  skin  (myxoedema,  diabetes,  long-standing  pyrexia,  or 
wasting  disease)  is  easily  appreciated  as  we  pass  the  hand  over  the 
surface  of  the  thorax  or  down  the  arms.  The  same  manipulation 
often  brings  to  our  attention  in  cases  of  alcoholism  an  unusually 
smooth  and  satiny  quality  of  the  cutaneous  surface. 

II.  The  Pulse;  Preliminary  Study. 

Fifty  years  ago  the  study  of  the  pulse  furnished  the  physician 
with  most  of  the  available  evidence  regarding  the  condition  of  the 
heart.  At  present  this  is  not  the  case.  With  the  increase  of  our 
knowledge  of  the  direct  physical  examination  of  the  heart  and  of 
the  various  methods  of  measuring  the  systolic  or  diastolic  pressure 
on  the  peripheral  arteries,  the  amount  of  information  furnished 
exclusively  by  the  pulse  proportionately  decreased,  until  within  the 
past  ten  years  when  the  researches  of  Wenckebach,  the  studies  of 
MacKenzie  upon  the  venous  pulse,  the  electrocardiographic  work  of 
Einthoven  have  focussed  attention  anew  upon  vascular  phenomena 
as  a  means  of  estimating  heart  function. 

Despite  the  more  accurate  and  detailed  information  to  be 
obtained  by  the  newer  methods,  simple  manual  palpation  of 
the  radial  pulse  is  still  an  important  factor  in  diagnosis,  prognosis, 
and  treatment,  and  will  remain  so,  because  it  gives  us  quickly, 
succinctly,  and  in  almost  every  case  a  great  deal  of  valuable  in- 
formation which  it  would  take  more  time  and  trouble  to  obtain 
in  any  other  way.  As  we  feel  the  pulse,  we  get  at  once  a  fact  of 
central  importance  in  the  case ;  by  the  pulse  the  steps  of  our  sub- 
sequent examination  are  guided.  In  emergencies  or  accidents 
the  pulse  gives  us  our  bearings  and  tells  us  whether  or  not 
the  patient's  condition  is  one  demanding  immediate  succor — e.g., 
hypodermic  stimulation — and  whether  the  outlook  is  bright  or  dark. 
To  gather  this  same  information  in  any  other  way  would  involve 
losing  valuable  time. 

Again,  when  one  has  to  see  a  large  number  of  patients  in  a  short 
time,  as  in  visiting  a  hospital  ward  or  on  the  crowded  days  of  private 
practice,  the  pulse  is  an  invaluable  short  cut  to  some  of  the  most 
important  data. 


PALPATION  AND  THE  STUDY  OF  THE  PULSE  101 

Moreover,  there  are  some  important  inferences  which  the  pulse 
and  only  the  pulse  enables  us  to  make.  They  are  not  numerous,  but 
their  value  may  be  great.  Delay  in  one  radial  pulse  when  taken  in 
connection  with  other  signs  may  furnish  decisive  evidence  of  aneu- 
rism of  the  aortic  arch;  aortic  stenosis  is  a  lesion  which  cannot  be 
diagnosed  unless  the  pulse  shows  certain  characteristic  features; 
arterial  degeneration  may  betray  its  presence  chiefly  in  the  periph- 
eral arteries. 

Since,  then,  direct  palpation  of  the  radial  pulse  furnishes  informa- 
tion of  crucial  importance  in  a  few  diseases,  and  is  a  quick,  reliable, 
and  convenient  indication  of  the  general  condition  of  the  circulation  in 
all  cases,  it  is  essential  that  we  should  study  it  most  carefully  both 
in  health  and  in  disease. 

How  to  Feel  the  Pulse. 

(a)  We  usually  feel  for  the  pulse  in  the  radial  artery  because 
this  is  the  most  superficial  vessel  which  is  readily  available.  Oc- 
casionally, as  when  the  wrists  are  swathed  in  surgical  dressings  or 
tied  up  in  a  straight- jacket,  we  make  use  of  the  temporal,  facial, 
or  carotid  arteries.  Hoover  believes  that  the  femoral  artery  is  better 
than  the  radial  when  one  wishes  to  judge  blood  pressure,  but  this 
datum  seems  to  me  one  that  should  always  be  secured  by  instrumental 
means.  In  searching  for  evidence  of  arterial  degeneration  the  bra- 
chial arteries  should  always  be  palpated. 

(6)  Both  radials  should  always  be  felt  at  the  same  time.  By 
making  this  a  routine  practice  many  mistakes  are  avoided  and 
any  difference  in  the  two  pulses  is  appreciated. 

(c)  The  tips  of  three  fingers  (never  the  thumb)  should  be  laid 
upon  the  artery,  and  the  following  points  noted: 

1.  The  rate  of  the  pulse. 

2.  The  rhythm  of  the  pulse. 

3.  The  amount  of  force  necessary  to  obliterate  it  (compressibility). 

4.  The  size  and  shape  of  the  pulse  wave. 

5.  The  size  and  position  of  the  artery. 

6.  The  condition  of  the  artery  walls. 

Each  of  these  points  will  now  be  considered  in  detail. 

I.   The  Rate  of  the  Pulse. 

In  the  adult  male  the  pulse  averages  72  to  the  minute,  in  the 
female  80.  In  children  it  is  considerably  more  frequent.  At  birth 
it  averages  about  130,  and  until  the  third  year  it  is  usually  above 


102  PHYSICAL  DIAGNOSIS 

loo.  In  some  families  a  slow  pulse,  60  or  less,  is  hereditary;  on  the 
other  hand,  it  is  not  very  rare  to  observe  a  permanent  pulse  rate  of 
100  or  more  in  a  normal  adult  (see  below,  p.  247).  Exercise  or  emo- 
tion quickens  the  pulse  very  markedly,  and  after  food  it  is  somewhat 
accelerated.  Some  account  of  the  causes  of  pathological  quicken- 
ing or  slowing  of  the  pulse  will  be  found  on  pages  247  and  248. 

2.  Rhythm. 

The  pulse  may  be  irregular  in  force,  in  rhythm,  or  (as  most  com- 
monly happens)  in  both  respects.  As  a  rule,  irregularities  in  force 
are  the  more  serious,  and  form  part  of  that  absolute  type  of  arrhy- 
thmia which  is  now  known  to  be  associated  with  auricular  fibrillation 
(see  below,  p.  115).  Intermittence  or  irregularity  in  rhythm  alone 
is  usually  less  ominous. 

Special  types  of  irregularity  will  be  discussed  later  in  connection 
with  the  instrumental  study  of  phlebograms  and  arteriograms. 

In  general  it  may  be  said  (a)  that  irregularity  in  the  force  of  the 
pulse  beats  is  a  serious  sign,  if  overexertion  and  temporary  toxic 
influences  (tobacco,  tea,  etc.)  can  be  ruled  out;  (&)  that  it  is  far  more 
serious  when  occurring  in  connection  with  diseases  of  the  aortic  valve 
than  in  mitral  disease;  and  (c)  that  it  often  occurs  in  connection  with 
sclerosis  of  the  coronary  arteries  and  myocarditis. 

3.   Compressihility,  or  Systolic  Arterial  Pressure. 

There  is  no  single  datum  concerning  the  pulse  more  important 
than  the  amount  of  force  needed  to  obliterate  its  beat.  Until  recently 
we  have  had  no  more  accurate  method  of  measuring  the  systolic 
blood  pressure  than  that  depending  on  direct  digital  compression. 
This  method  seems  to  me  so  unreliable  that  it  should  be  abandoned 
in  favor  of  the  instrumental  method  presently  to  be  described. 

4.   The  Size  and  Shape  of  the  Pulse  Wave. 

Of  the  use  of  the  sphygmograph  for  representing  pulse  waves 
I  shall  speak  later.  The  points  discussed  in  this  section  are  appre- 
ciable to  the  fingers. 

I.  The  size  of  the  pulse  wave — ^the  height  to  which  it  lifts  the 
finger — depends  on  two  factors  : 

(a)  The  force  of  the  cardiac  contractions  (systoHc  arterial  pressure). 

ih)  The  tightness  or  looseness  of  the  artery  {tension,  or  diastolic 
pressure). 


PALPATION  AND  THE  STUDY  OF  THE  PULSE  103 

If  the  arteries  are  contracted  and  small,  the  pulse  wave  corre- 
sponds, while  if  they  are  large  and  relaxed,  it  needs  only  a  moderate 
degree  of  power  in  the  heart  to  produce  a  high  pulse  wave.  If  the 
tension  remains  constant  the  size  of  the  pulse  wave  depends  on  the 
force  of  the  heart's  contraction.  If  the  heart  power  remains  con- 
stant, the  size  of  the  pulse  wave  depends  on  the  degree  of  vascular 
tension.  Vascular  tension  is  estimated  in  ways  to  be  described 
presently,  and  after  allowing  for  it,  we  are  enabled  to  estimate  the 
power  of  the  heart's  contractions  from  the  height  of  the  pulse  wave. 

II.  The  shape  of  the  pulse  wave  is  also  of  importance. 

(a)  It  may  have  a  very  sharp  summit,  rising  and  falling  back 
again  suddenly;  this  is  known  as  an  ill-sustained  pulse  or  a  "  Corrigan  " 
pulse,  and  may  be  due  to  a  lack  of  sustained  propulsive  power  in  the 
contracting  heart  muscle,  to  low  vascular  tension^  diminished  vascular 
elasticity,  or  to  a  combination  of  the  three  causes.  A  weak  heart 
with  low  arterial  tension  often  produces  such  a  pulse  wave — decep- 
tively high  and  giving  at  first  an  impression  of  power  in  the  heart 
wall,  but  ill  sustained  and  easily  compressible.  This  is  the  "bounding 
pulse"  of  early  infectious  processes.  An  exaggeration  of  this  type  of 
pulse  is  to  be  felt  in  aortic  regurgitation  (see  page  221)  and  in  many 
cases  of  arteriosclerosis. 

(6)  In  sharp  contrast  with  the  above  is  the  pulse  wave  which 
lifts  the  finger  gradually  and  slowly,  sustains  it  for  a  relatively  long 
period,  and  then  sinks  gradually  down  again.  Such  a  pulse  with  a 
"long  plateau"  instead  of  a  sharp  peak  is  to  be  felt  most  distinctly 
in  aortic  stenosis,  less  often  in  mitral  stenosis  and  other  conditions 
(see  page  229). 

(c)  The  dicrotic  pulse  wave  is  one  in  which  the  secondary  wave, 
which  the  sphygmograph  shows  to  be  present  in  the  normal  pulse, 
is  much  exaggerated,  so  that  a  distinct  "echo"  of  the  primary  wave 
is  felt  after  each  beat.  If  the  heart  is  acting  rapidly,  this  dicrotic 
wave  does  not  have  time  to  fall  before  it  is  interrupted  by  the  primary 
wave  of  the  next  beat,  and  so  appears  in  the  sphygmographic  tracing 
as  a  part  of  the  up-stroke  of  the  primary  wave.  This  is  known  as  the 
"anacrotic  pulse." 

(d)  The  shape  of  the  high-tension  pulse  wave  will  be  described 
in  the  next  paragraph. 

5.   Tension,  or  Diastolic  Arterial  Pressure. 

The  degree  of  contraction  of  the  vascular  muscles  determines 
the  size  of  the  artery  and  (to  a  great  extent)  the  tension  of  the  blood 


104  PHYSICAL  DIAGNOSIS 

within  it.  But  if  the  heart  is  acting  feebly,  there  may  be  so  little 
blood  in  the  arteries  that  even  when  tightly  contracted  they  do  not 
subject  the  blood  within  them  to  any  considerable  degree  of  tension. 
To  produce  high  tension,  then,  we  need  two  factors:  a  certain  degree 
of  power  in  the  heart  muscle,  and  contracted  arteries.  To  produce 
low  tension  we  need  only  relaxation  of  the  arteries,  and  the  heart  may 
be  either  strong:  or  weak. 


Fig.  90. — Sphygmographic  Tracing  of  Low  Tension  Pulse. 

The  pulse  of  low  tension  collapses  between  beats,  so  that  the  ar- 
tery is  less  palpable  than  usual  or  cannot  be  felt  at  all.  Normally, 
the  artery  can  just  be  made  out  between  beats,  and  any  consider- 
able lowering  of  arterial  tension  makes  it  altogether  impalpable 
except  during  the  period  of  the  primary  wave  and  of  the  dicrotic 
wave,  which  is  often  very  well  marked  in  pulses  of  low  tension.  The 
shape  of  the  wave  under  these  conditions  has  already  been  described 
(see  Fig.  90). 


Fig.  91. — Sphygmographic  Tracing  of  High  Tension  Pulse. 

The  pulse  of  high  tension  is  perceptible  between  beats  as  a  distinct 
cord  which  can  be  rolled  between  the  fingers,  like  one  of  the  tendons 
of  the  wrist.  It  is  also  difficult  to  compress  in  most  cases,  but  this 
may  depend  rather  on  the  heart's  power  than  on  the  degree  of  vas- 
cular tension.  A  high-tension  pulse  is  often  indistinguishable  from 
one  stiffened  by  arteriosclerosis  (vide  infra).  The  pulse  wave  is 
usually  of  moderate  height  or  low,  and  falls  away  slowly  with  little 
or  no  dicrotic  wave  (see  Fig.  91). 


PALPATION  AND  THE  STUDY  OF  THE  PULSE  105 

6.   The  Size  and  Position  of  the  Artery. 

I  have  often  known  errors  to  occur  because  a  small  artery  is  mis- 
taken for  a  small  pulse  wave.  The  size  of  the  branches  of  the  arterial 
tree  varies  a  great  deal  in  different  individuals  of  the  same  weight 
and  height,  and  if  the  radial  is  unusually  small  and  a  hurried  ob- 
servation gives  us  the  impression  (true,  so  far  as  it  goes)  that  there  is 
very  little  in  the  way  of  a  pulse  to  be  felt,  we  are  apt  to  conclude 
(wrongly,  perhaps)  that  the  heart's  work  is  not  being  properly  per- 
formed. The  effort  to  obliterate  such  a  pulse,  however,  may  set  us 
right  by  showing  that  despite  the  small  size  of  the  vessel  (and  con- 
sequently of  the  pulse  wave)  it  takes  as  much  force  as  it  normally 
does  to  obliterate  it.  But  in  many  cases  we  can  determine  the 
question  satisfactorily  often  by  using  some  instrument  for  measuring 
arterial  pressure.  Thus,  a  small  pulse  wave  (in  a  congenitally  small 
artery)  may  be  distinguished  from  a  weak  pulse.  From  the  contracted 
artery  of  high  vascular  tension  we  distinguish  the  congenitally  small 
artery  because  the  latter  is  not  to  be  rolled  beneath  the  fingers,  and 
is  not  more  than  normally  palpable  between  the  pulse  beats.  Blood 
pressure  measurements,  however,  are  the  only  reliable  guide  in  such 
cases. 

Not  infrequently  the  nurse  reports  in  alarm  that  the  patient  has 
no  pulse,  when  in  reality  the  pulse  is  excellent  but  the  artery  mis- 
placed so  as  to  be  impalpable  in  the  ordinary  situation.  It  may  be 
simply  more  deeply  set  than  normal,  so  that  the  fingers  cannot  get 
at  it,  or  it  may  run  superficially  over  the  end  of  the  radius  toward 
the  "anatomical  snuff  box."  Other  anomalies  are  less  common. 
As  a  rule,  the  other  radial  artery  is  normally  placed  and  can  be  used 
as  a  standard,  but  occasionally  both  radials  are  anomalous  and  we 
may  be  compelled  to  use  the  temporal  or  facial  instead. 

7.   The  Condition  of  the  Artery  Walls. 

Arterio-sclerosis^  is  manifested  in  the  peripheral  arteries,  especially 
in  the  brachial,  in  the  following  forms : 

(a)   Simple  stiffening  of  the  arteries  without  calcification. 

(6)   Tortuosity  of  the  arteries. 

(c)    Calcification. 

Simple  stiffening  without  calcification  is  due  to  fibrous  thickening 
of  the  intima  and  produces  a  condition  of  the  arteries  not  manually 

^  "  Arterio-sclerosis "  is  here  used  to  mean  any  anatomical  change  in  the  arterial  walls 
that  permanently  diminishes  their  elasticity.     No  single  histological  entity  is  referred  to. 


106  PHYSICAL  DIAGNOSIS 

to  be  distinguished  from  high  tension.  The  artery  can  be  rolled  under 
the  fingers,  stands  out  visibly  between  the  heart's  beats,  but  is  not 
incompressible,  has  a  smooth  surface,  and  is  not  always  tortuous. 
If  it  is  tortuous  as  well  as  stiff,  we  may  conclude  that  there  is  an 
histological  degeneration  at  any  rate,  whether  or  not  there  is  increased 
tension  as  well.  In  the  vast  majority  of  cases  the  two  conditions 
are  associated  and  do  not  need  to  be  distinguished. 

The  normal  radial  artery  is  straight;^  hence  any  deviation  is 
evidence  of  changes  in  its  walls  and  is  easily  recognized  as  we  run 
our  fingers  up  and  down  the  vessel. 

Calcification  of  an  artery  produces  usually  a  heading  of  its  sur- 
face. As  we  move  the  fingers  along  the  artery,  quickly  and  with 
very  slight  pressure,  a  series  of  transverse  ridges  or  beads  can  be 
felt.  The  qualities  of  the  pulse  wave  within  can  usually  be  appre- 
ciated fairly  well,  in  this  type  of  artery,  but  in  very  advanced  cases 
the  calcification  is  diffuse  and  converts  the  radial  into  a  rigid  "pipe 
stem" — absolutely  incompressible — unless  we  break  the  calcified 
coat — and  easily  mistaken  for  a  tendon.  In  such  an  artery  no  pulse 
can  be  felt. 

Such  are  the  points  to  be  observed  in  the  preliminary  study  of  the 
pulse.  To  enumerate  the  characteristics  of  the  pulse  in  the  many  dis- 
eases in  which  it  affords  us  valuable  information  is  beyond  the  scope  of 
this  book.  The  qualities  to  be  expected  in  the  pulse  in  connection 
with  the  different  diseases  of  the  heart  are  described  in  the  sections  on 
those  diseases.  Here  it  will  suffice  to  enumerate  some  of  the  con- 
ditions in  which  vascular  tension  is  usually  increased  or  diminished. 

Low  tension  is  produced  by  moderate  exercise,  by  warmth  {e.g., 
a  warm  bath),  by  food.  Among  pathological  conditions  we  may 
mention  Addison's  disease,  tuberculosis,  pernicious  anaemia,  and 
many  infectious  fevers. 

High  tension  is  produced  by  cold  {e.g.,  cold  bathing,  malarial 
chills).  As  a  rule,  the  tension  of  the  pulse  increases  with  age  and  is 
high  after  the  fiftieth  year.  Hysteria  and  migraine  are  said  to  be 
associated  with  increased  vascular  tension,  and  it  is  almost  always 
high  during  and  before  eclamptic  spasms.  Increase  of  intracranial 
pressure  (as  by  cerebral  hdemorrhage  or  trauma)  has  a  similar  but  more 
lasting  effect.  Most  frequent  among  pathological  conditions  as  causes 
of   high   tension   are   chronic   nephritis   and  arteriosclerosis  with  the 

'  Tortuosity  in  the  temporal  artery,  however,  is  normal. 


PALPATION  AND   THE   STUDY   OF  THE  PULSE  107 

various  diseases  in  which  arterio-sclerosis  is  a  factor  (gout,  lead  poison- 
ing, diabetes  of  fat  old  people) . 

In  valvular  heart  disease  without  nephritis  or  arterio-sclerosis 
the  tension  is  usually  normal  or  slightly  lowered. 

Arterial  Pressure  and  the  Instruments  for  Measuring  It. 

Within  the  past  decade  a  number  of  instruments  have  come 
into  use,  the  object  of  which  is  to  tell  us  with  some  approach  to  accu- 
racy the  lateral  pressure  in  the  peripheral  arteries.  We  have  long 
attempted  to  estimate  this  pressure,  by  simple  digital  compression 
and  palpation,  and  no  doubt  these  methods  in  the  hands  of  skilled 
observers  will  always  have  a  field  of  usefulness;  but  it  seems  to  me 
clear  that  by  the  instruments  about  to  be  described  we  can  obtain 
data  in  regard  to  the  force  of  the  heart's  contractions  and  the  tension 
of  the  peripheral  arteries  more  accurate  and  more  reliable  than  those 
furnished  by  digital  examination.  This  is  especially  true  of  com- 
parative records,  as,  for  example,  if  one  attempts  to  compare  the 
tension  of  the  pulse  to-day  with  what  it  was  yesterday,  when  one  has 
felt  many  pulses  in  the  interim.  Another  objection  to  estimates 
of  pulse  pressure  based  on  digital  examination  results  from  the  fact 
that  the  size  of  the  artery  itself  is  apt  to  be  a  confusing  factor. 

Among  the  many  instruments  introduced  within  the  past  decade 
we  may  distinguish  (i)  those  which  aim  to  estimate  the  amount  of 
compression  which  has  to  be  exerted  upon  a  given  artery  in  order  to 
arrest  the  onward  flow  of  blood  in  it,  and  (2)  those  which  seek  to 
estimate  also  the  amount  of  pressure  in  a  given  artery  at  the  moment 
when  its  wall  makes  the  widest  excursion  or  oscillation. 

Instruments  of  the  first  type  are  said  to  measure  systolic  pressure, 
and  those  of  the  second  type  to  measure  also  diastolic  pressure.  Here 
as  elsewhere  in  this  book  I  shall  describe  only  such  instruments  and 
methods  as  are  clinically  available  and  only  such  as  seem  to  me  the 
best.  I  shall  not  attempt  to  cover  the  whole  field  or  to  conceal 
such  personal  preferences  as  are  based  on  experience. 

For  clinical  work  I  have  found  the  instruments  of  the  Riva-Rocci 
type  by  far  the  best  (t.^.^Faught's,  Stanton's  and  Mercur's).  Despite 
the  inconveniences  of  transporting  a  mercury  column  it  remains  the 
most  reliable  method.  Instruments  of  any  other  type  (e.g.  those 
using  springs  to  measure  pressure)  are  always  getting  out  of  order 
and  have  to  be  constantly  standardized  by  comparison  with  the 
mercury  column.     Gaertner's  tonometer  is  very  inaccurate. 


108 


PHYSICAL  DIAGNOSIS 


All  instruments  of  the  Riva-Rocci  type  consist  essentially  of  an 
inflatable  rubber  armlet,  so  arranged  that  it  can  be  fitted  closely 
around  the  upper  arm,  a  mercury  manometer  of  the  ordinary  type, 
and  an  air-pump  (see  Figs.  90  and  91).     The  air  forced  from  the  pump 


Fig.  92 — Mercur's  Type  of  Riva-Rocci  Sphygmomanometer. 

is  distributed  into  the  rubber  armlet  and  into  the  manometer  at  the 
same  time,  and  experiments  have  shown  that  the  actual  pressure  in  the 
armlet  is  practically  identical  at  any  given  time  with  that  in  the 
manometer. 

I .   Measurement  of  Systolic  or  Maximum  Pressure. 

To  use  the  instrument  for  measuring  systolic  blood  pressure  we 
pump  in  air  until  the  radial  pulse  stops,  and  at  that  instant  note  the 
height  of  the  mercury  column.  The  reading  thus  obtained  is  taken 
to  represent  the  systolic  or  maximum  pressure  in  the  brachial  artery. 
To  raise  the  mercury  column  slightly  above  the  point  at  which  the 
pulse  stops,  then  let  the  column  slowly  fall  and  note  the  point  on  the 
scale  at  which  we  feel  the  return  of  the  pulse  is  easier  and  no  less  accurate 
than  to  fix  the  point  at  which  the  pulse  first  disappears. 


PALPATION  AND  THE  STUDY  OF  THE  PULSE 


109 


It  is  true  that  the  air  within  the  rubber  armlet  has  to  overcome 
not  only  the  pressure  within  the  radial  artery,  but  the  resistance  of 
the  artery  wall  and  the  elasticity  of  the  soft  parts  around  it.  The 
former  factor  has  been  shown  to  represent  a  pressure  of  not  more 
than  2  or  3  mm.  Hg,  provided  the  artery  walls  are  normal.      If  arterio- 


FiG.  93. — Faught's  Type  of  Riva  Rocci  Sphygmomanometer. 

sclerosis  is  present,  it  has  been  estimated  by  Herringham  that  the 
artery  may  oppose  a  resistance  of  15  to  20  mm.  Hg.  The  more  care- 
fully conducted  experiments  of  Janeway,  however,  convince  me  that 
Herringham  is  wrong  and  that  sclerosed  arteries  offer  a  direct  resist- 
ance of  less  than  5  mm.  Hg.  The  amount  of  error  thus  introduced 
is  not  of  importance. 


no  PHYSICAL  DIAGNOSIS 

The  resistance  of  the  soft  parts  around  the  artery  is  a  factor  of  no 
importance,  provided  the  compressing  armlet  is  at  least  12  cm.  wide. 
A  huge  arm  gives  no  higher  reading  than  a  shrivelled  one,  as  has  been 
shown  by  Janeway  in  a  patient  one  of  whose  arms  was  congenitally 
atrophied  while  the  other  was  enormous. 

The  instrument  is  a  very  simple  and  quick  one  to  use,  needing 
very  little  practice  and  not  more  than  a  minute  or  a  minute  and  a 
half  for  a  single  reading.  The  chief  objection  to  it  is  its  bulk  and 
fragility. 

Systolic  pressure  may  also  be  measured  by  listening  with  the 
stethoscope  over  the  brachial  artery  just  peripheral  to  the  cuff,  and 
noting  when  the  tapping  systolic  sound  disappears. 

2 .   Measurement  of  Diastolic  Pressure. 

The  auscultatory  method  (Korotkoff)  just  described  is  especially 
useful  in  the  measurement  of  diastolic  or  minimum  blood-pressure. 
The  air  is  allowed  gradually  to  leak  out  of  the  cuff  and,  as  the  mercury 
column  descends,  one  listens  with  the  stethoscope  just  below  the  cuff. 
The  sharp  systolic  sound  reappears,  becomes  loud,  and  remains  so 
until  we  reach  a  point  30-45  mm.  below  the  systolic  reading.  Then 
the  sound  rapidly  disappears.  Its  point  of  disappearance  or  of  very 
marked  weakening  corresponds  within  5  mm.  to  the  diastolic  pressure 
as  estimated  by  the  most  accurate  and  complicated  instruments,  such 
as  Erlanger's. 

3.  Normal  Readings. 

With  any  of  the  various  types  of  Riva-Rocci  instrument  mentioned 
on  p.  107,  the  readings  in  healthy  adults  at  rest  are  approximately  as 
follows:     Systolic,    1 10-135    mm.  Hg.     Diastolic,  60-90  mm.  Hg. 

The  "pulse  pressure,"  i.e.,  the  difference  between  any  individual's 
systolic  and  diastolic  pressure,  averages  30-45  mm.  Hg. 

In  women  all  the  figures  run  about  10  mm.  lower  than  in  men. 
Children  under  2  years,  75-90  mm.  In  older  children,  90-110  mm. 
Excitement  or  exercise  raise  the  pressure  temporarily  but  considerably. 
It  is  5-10  mm.  lower  in  recumbency  than  in  the  sitting  position. 

The  instrument  devised  by  Erlanger  (Johns  Hopkins  Hospital 
Reports,  1904,  Vol.  XII.)  gives  very  accurate  readings  both  for 
systolic  and  for  diastolic  pressure.  Its  bulk,  delicacy,  the  difficulty 
of  keeping  it  in  good  order,  and  the  amount  of  time  needed  to  secure 
a  reading  will  prevent  its  general  use  in  clinical  work. 


ARTERIAL  PRESSURE  111 

4.  The  Use  of  the  Data  Obtained  by  these  Instruments. 

Whenever  it  is  important  for  us  to  know  the  tension  of  the  per- 
ipheral arteries,  a  sphygmomanometer  is  indispensable.  The  more  I 
use  the  instrument,  the  more  firmly  I  am  convinced  that  digital 
measures  of  blood  pressure  are  often  ludicrously  wrong.  The  Riva- 
Rocci  instrument  as  modified  by  Faught,  Janeway  or  Stanton  has 
now  secured  a  firm  position  in  the  routine  work  of  good  clinicians 
all  over  this  country.  • 

High  Systolic  Blood-pressure. 

Slight  increase  of  systolic  blood-pressure  is  (fortunately  for  our 
diagnosis)  rarely  encountered.  As  a  rule  if  we  find  blood  pressure 
high  it  is  very  high,  obviously  high,  160-250  mm.  Hg.,  and  not  in 
the  more  dubious  immediate  regions  (140-160).  In  at  least  95  per 
cent,  of  the  cases  a  permanent  or  long  standing  hypertension  is 
associated  with  obvious  hypertrophy  of  the  heart  and  due  to  all  the 
well  known  causes  of  cardiac  hypertrophy  except  rheumatic  endocarditis 
with  valve  lesions.     Accordingly  the  causes  of  high  blood  pressure  are :. 

1.  Chronic  nephritis.^ 

2.  Arteriosclerosis.'^ 

3.  Acute  compression  of  the  brain  (as  by  apoplexy,  skull  fractures, 
meningitis,  and  other  rapidly  advancing  intracranial  lesions). 

4.  Puerperal  eclampsia. 

Less  important  are  the  transitory  effects  of  acute  pain  (as  in  gout, 
tabetic  crises,  lead  colic,  biliary  colic  and  during  child  birth). 

Neurasthenia  and  insanity  are  often  mentioned  as  causes  of  hyper- 
tension, but  I  suspect  other  causes  in  the  background. 

Clinically  it  is  easy  to  exclude  in  most  cases  all  the  causes  of 
hypertension  just  listed  except  two:  chronic  nephritis,  and  arterio- 
sclerosis. Hence  vascular  hypertension  and  high  blood  pressure  should 
always  make  us  suspect  these  diseases  even  though  the  urine  and  the 
peripheral  arteries  give  no  convincing  sign  of  them. 

We  may  thus  detect  in  life  insurance  examinations  and  elsewhere 
many  cases  that  would  otherwise  pass  altogether  unnoticed.  On  the 
other  hand  the  negative  value  of  a  normal  blood-pressure  is  very  great. 
It  helps  us  to  exclude  chronic  nephritis  in  the  vast  majority  of  cases^ 
and  raises  a  presumption  against  the  existence  of  arteriosclerosis. 

^  Especially  if  the  thoracic,  aortic  or  splanchnic  arteries  are  extensively  diseased. 
^  i.e.,  any  nephritis  of  more  than  a  few  months  duration. 


112  PHYSICAL  DIAGNOSIS 

Low  Systolic  Blood-pressure. 

Much  less  valuable  in  diagnosis  are  the  abnormally  low  blood- 
pressure  readings.  We  seldom  get  much  help  from  them.  The 
lowest  readings  occur  in  Addison's  disease  (even  to  50  mm.),  in  per- 
nicious anaemia,  infectious  fevers  (tuberculosis,  pneumonia,  typhoid) 
and  surgical  "shock."  Occasionally  the  diagnosis  of  tuberculosis 
may  be  assisted  or  confirmed  if  hypertension  is  marked. 

Diastolic  Pressure. 

There  is  very  seldom  any  need  of  measuring  diastolic  pressure. 
Very  little  information  of  clinical  value  is  obtained  from  it.  It  is 
relatively  low  {i.e.,  the  pulse  pressure  relatively  high)  in  aortic  regur- 
gitation and  in  some  cases  of  arteriosclerosis,  anaemia,  and  Graves' 
disease;  but  no  diagnostic  or  prognostic  value  attaches  to  it  in  my 
experience  though  it  has  been  measured  along  with  the  systolic 
pressure  as  a  matter  of  routine  in  my  wards  for  a  considerable  period. 
The  general  practitioner  may  safely  disregard  it,  bearing  in  mind 
that  in  acute  aortic  regurgitation  the  high  systolic  pressure  is  balanced 
by  a  low  diastolic  pressure. 


CHAPTER  VI. 

ARTERIOGRAMS,  PHLEBOGRAMS,  AND 
ELECTROCARDIOGRAMS. 

In  the  last  edition  of  this  book  I  referred  to  the  sphygmograph  as  a 
fascinating  but  useless  little  toy.  As  an  instrument  for  recording  the 
shape  of  pulse  waves  it  went  out  of  use,  because  it  was  hopelessly 
unreliable.  To  record  the  time  relations  of  the  pulse  waves  it  has 
come  back  into  use,  so  that  Lewis,  one  of  the  most  distinguished  in- 
vestigators in  the  field  of  phlebographic  and  electrocardiographic 
work,  is  able  to  state,  in  his  recent  monograph^  that  "the  mechanism 
of  the  heart  may  be  identified  in  the  majority  of  cases  in  which  it  is 
irregular  by  a  careful  examination  of  the  radial  pulse  tracing  alone." 

We  may  come  back  to  the  sphygmograph  and  to  the  results  of 
auscultation,  and,  interpreting  our  old  data  in  the  hght  of  newer 
researches,  we  may  be  able  to  read  far  deeper  and  more  intelligible 
meanings  into  them.  But  whether  this  is  true  or  not  I  feel  convinced 
by  my  own  experience  with  tracings  of  the  venous  pulse  and  by  my 
study  of  others'  work  with  electrocardiograms  that  neither  method 
is  likely  ever  to  be  used  by  the  practitioner  for  whom  this  book  is 
intended.  I  desire  therefore,  in  this  chapter,  to  state  the  results 
accomplished  by  the  newer  methods  without  attempting  to  describe  or 
recommend  the  technique. 

The  advances  achieved  through  phlebographic  and  electrocardio- 
graphic work  seem  to  consist  of  a  better  knowledge  of: 

1.  Heart  block,  partial  or  total. 

2.  Auricular  fibrillation  and  absolute  irregularity  of  the  pulse. 

3.  Paroxysmal  tachycardia. 

4.  Premature  contractions  of  auricle  or  ventricle. 

5.  Coupling  of  heart  beats  and  alternation. 

Heart  Block. 

In  the  normal  heart  the  impulse  of  contraction  starts  at  the  sino- 
auricular  node,  a  mass  of  specialized  muscular  tissue  at  the  superior 

1  Thomas  Lewis:  "The  Mechanism  of  the  Heart  Beat,"  Shaw  &  Sons,  London,  1911, 
a  work  to  which  I  am  profoundly  indebted. 

8  113 


114  PHYSICAL  DIAGNOSIS 

cavo-auricular  junction,  spreads  through  the  bundle  of  His  in  the 
membranous  interventricular  septum,  and  is  distributed  thence  through 
the  Ptirkinje  fibres  to  the  ventricles  and  their  papillary  muscles.  Since 
the  sino-auricular  node  just  mentioned  is  apparently  responsible  for 
the  origination  of  beat  after  beat,  and  determines  the  rate  of  the  heart, 
it  is  now  often  spoken  of  as  "the  pace-maker." 

If  the  transmission  of  impulses  is  blocked  by  disease  in  the  bundle 
of  His  (usually  gumma  or  fibro-calcareous  degeneration),  we  get  the 
following  series  of  disasters,  each  worse  than  the  last- 

(a)  A  prolongation  of  the  interval  between  auricular  systole  and 
ventricular  systole  ("the  A-s — V-s  interval,"  normally  from  .i  to  .2 
of  a  second)  to  twice  or  thrice  its  normal  length. 

(b)  "Dropped  beats,"  i.e.,  an  occasional  "silence"  of  the  ventricle 
in  answer  to  the  regular  auricular  contraction  preceding  it. 

(c)  Regularly  recurring  "dropped  beats"  every  tenth  beat  or 
oftener. 

(d)  The  establishment  of  a  3:1  or  2:1  rhythm,  i.e.,  three  or  two 
beats  of  the  auricle  for  every  beat  of  the  ventricle. 

(e)  Complete  dissociation  of  auricle  and  ventricle.  No  impulses 
pass  down.  The  ventricle  may  stand  still  for  good  and  all  or  may 
gradually  initiate  a  slow  rhythm  of  its  own  (approximately  32  per 
minute) . 

If  the  ventricular  silence  lasts  three  to  five  seconds  the  patient 
usually  loses  consciousness  for  a  moment.  Silence  of  ten  to  twenty 
seconds  usually  results  in  epileptiform  convulsions.  When  these 
cerebral  phenomena  are  associated  with  more  or  less  heart  block  we 
have  the  Stokes-Adams  syndrome.  Silence  over  ninety  seconds  means 
death.      (Lewis,  loc.  cit.,  p.  266.) 

Heart  block  in  slight  grades  (see  (a)  above)  is  often  a  result  of 
"rheumatic"  infection  of  the  heart,  especially  (as  MacKenzie  and 
Lewis  have  shown)  in  cases  of  mitral  stenosis.  Lewis  found  an  As — 
Vs  interval  of  over  .2  seconds  in  nearly  17  per  cent,  of  84  cases  of 
comparatively  well-compensated  out-patient  cases  of  mitral  stenosis. 
In  ward  patients  it  must  be  far  more  frequent. 

When  the  As — Vs  interval  is  already  increased,  the  act  of  swallowing, 
pressure  on  the  vagus  in  the  neck  or  the  administration  of  digitalis 
may  increase  the  grade  of  heartblock,  and  may  lead  to  a  2:1  or  3:1 
rhythm,  or  to  complete  dissociation  of  auricle  and  ventricle,  always  a 
very  serious  condition. 

To  establish  the  presence  of  heart  block  we  need  venous  pulse 
tracings  made  synchronously  with  arterial  pulse  tracings,  so  that  the 


ARTERIOGRAMS,  PHLEBOGRAMS,  AND  ELECTROCARDIOGRAMS     115 

time  relation  of  auricular  contraction  (shown  in  the  neck  veins)  to 
ventricular  contraction  (shown  in  the  carotid  or  radial  artery)  can  be 
demonstrated.  MacKenzie's  polygraph  records  upon  the  same  strip 
of  paper  the  movements  of  the  auricle  (neck  vein),  of  the  ventricle 
(radial  pulse  or  carotid),  and  of  a  time  marker  from  which  we  can  cal- 
culate very  exactly  any  delay  in  the  passage  of  the  contraction  wave 
from  auricle  to  ventricle.  Sometimes  we  can  see  in  the  neck  or  hear 
with  the  stethoscope^  something  corresponding  to  the  auricular  move- 
ments, and,  comparing  these  facts  with  the  palpable  radial  impulse, 
may  recognize  the  severer  grades  of  heart  block,  but  no  certainty 
can  be  obtained  without  the  use  of  venous  pulse  tracings  or  electro- 
cardiograms. In  the  latter  we  have  a  record  of  the  electrical  changes 
corresponding  to  the  earliest  contraction  wave  in  the  auricles  and  in 
the  ventricles  respectively — the  two  waves  recorded  in  the  same 
tracing  so  that  no  time  comparisons  or  measurements  of  different 
curves  are  necessary. 

Luckily  for  those  who  cannot  get  the  time  and  money  necessary 
for  the  use  of  these  methods,  there  are  relatively  few  cases  in  which  it 
is  imperatively  necessary  for  any  purpose  of  diagnosis,  prognosis,  or 
treatment  that  we  should  recognize  heart  block.  Were  it  a  commoner 
or  a  more  curable  condition  the  general  practitioner  would  sometimes 
be  at  a  great  disadvantage.  As  it  is,  we  can  generally  recognize  and 
treat  the  disease  underlying  heart  block  with  about  the  same  measure 
of  success  whether  the  heart  block  itself  escapes  us  or  not;  while  in 
heart  block  itself  there  is  no  effective  treatment  and  no  more  definite 
prognosis  than  one  could  give  from  a  knowledge  of  the  underlying 
disease. 

-  Auricular   Fibrillation. 

The  researches  of  MacKenzie  in  1904-5  brought  out  the  fact 
that  when  a  beat  is  absolutely  and  perpetually  irregular,  i.e.,  when  no 
two  successive  beats  have  the  same  duration  (as  shown  by  a  radial 
pulse  tracing) ,  the  venous  pulse  tracing  shows  no  sign  of  the  normal 
auricular  wave,  but  corresponds  with  the  ventricular  systole.  This 
was  thought  at  first  to  be  due  to  auricular  paralysis,  but  further 
electrocardiographic  research  has  brought  convincing  evidence  that 
the  auricle  is  in  fact  fibrillating,  i.e.,  the  seat  of  innumerable,  inco- 

^  Stokes  noted  that  the  dropped  beats  (auricular  movements)  in  heart  block  produced 
"small  sounds  which  may  give  the  illusion  of  reduplication  of  either  sound."  Hirschf elder 
describes  them  as  "very  soft  distant  sounds  like  the  ticking  of  a  watch"  and  "best  heard 
along  the  left  sternal  margin." 


116  PHYSICAL  DIAGNOSIS 

ordinate  .  contractions,  each  limited  to  a  small  bundle  of  muscle 
fibres.  The  fibrillating  auricle  is  quite  ineffectual  and  remains  in 
the  diastolic  position.  This  condition  has  long  been  familiar  in 
animal  experimentation,  but  has  not  until  the  last  few  years  been 
capable  of  recognition  in  man. 

Though  venous  pulse  tracings  and  electrocardiographic  records 
are  necessary  for  the  absolute  demonstration  of  auricular  fibrillation 
in  any  case,  the  presence  of  an  absolutely  irregular  pulse  {delirium 
cordis)  is  practically  equivalent  to  proof  of  auricular  fibrillation. 
The  exceptions  to  this  rule  are  negligible.  Since  the  auricles  are  of 
use  chiefly  as  temporary  reservoirs,  the  circulation  can  and  does  go 
on  for  months  and  years  despite  the  absence  of  any  effectual  con- 
traction of  the  auricle.  The  ventricle  and  the  peripheral  arteries  do 
the  work,  while  the  quivering,  distended  auricle  showers  impulses  at 
the  upper  end  of  His'  bundle.  "From  this  turmoil  of  the  auricle  a 
rapid  and  haphazard  succession  escape"^  along  the  bundle  and 
produce  the  absolutely  irregular  pulse. 

Auricular  fibrillation  thus  defined  produces  the  majority  of  all  the 
arrhythmias  clinically  observed.  The  irregular  pulse  of  most  cases 
of  rheumatic  endocarditis  and  of  myocardial  insufficiency  (the  fa- 
miliar arteriosclerotic  or  cardiorenal  types)  is  generally  of  this  kind. 
For  the  classification  of  arrhythmias  see  p.  248. 

Paroxysmal    Tachycardia. 

Excluding  the  periods  of  accelerated  heart  action  due  to  emotional 
strain,  muscular  exertion  and  infectious  disease,  we  have  but  one 
condition  in  which  the  heart  suddenly  becomes  rapid,  without  irregu- 
larity and  without  previous  evidence  of  cardiac  disease.  This  con- 
dition, long  known  as  paroxysmal  tachycardia,  has  been  illuminated 
by  recent  researches.  We  now  know,  through  electrocardiographic 
investigations,  that  while  in  the  vast  majority  of  these  tachycardias 
the  cardiac  impulse  comes  down  from  the  auricle  in  the  ordinary 
way,  it  does  not  arise  at  the  ordinary  place,  i.e.,  at  the  pace-maker, 
but  starts  up  like  an  insurrection  at  some  other  point  in  the 
auricular  muscle  ("heterogeneous  impulses").  Rarely  does  such  a 
tachycardia  originate  in  the  ventricle  or  in  the  bundle  of  His.  The 
present  condition  of  our  knowledge  is  fairly  represented  by  the 
following  diagram  from  Lewis  (loc.  cit.,  p.  191). 

This  diagram  suggests  the  "close  relation"  of  paroxysmal  tachy- 

'  Lewis,  loc.  cit.,  p.  247. 


ARTERIOGRAMS,  PHLEBOGRAMS,  AND  ELECTROCARDIOGRAMS     117 


A-V  JUNCTION 


II 


HI 


A-V  JUNCTION 


Fig.  94. — {after  Lewis). 

I.  Occasional  premature  beats,      ("auricular  extrasys tolas")  indicated  in  red. 

II.  A  short  period  of  paroxysmal  tachycardia,     indicated  in  red. 

III.  Absolute  arrhythmia  (auricular  fibrillation). 

Lewis'  experiments  indicate  that  these  three  disturbances  represent  three  increasing 
degrees  of  typical  impulse-formation,  "all  stages  of  one  or  the  same  process"  of  disorder 
or  civil  war  in  the  heart  muscle. 


118  PHYSICAL  DIAGNOSIS 

cardia  to  the  more  serious  auricular  fibrillation  just  described  and 
to  the  commoner  and  less  serious  form  of  arrhythmia  next  to  be 
discussed. 

Histologically  nothing  definite  is  known  about  the  cause  of  par- 
oxysmal tachycardia. 

Premature  Beats  (Extrasystoles)  . 

1 .  Ventricular. — Except  when  the  auricle  is  fibrillating,  premature 
beats  of  ventricular  origin  are  rare;  they  occur  occasionally  in  heart 
block  and  in  other  conditions  involving  a  tardy  impulse  from 
the  auricle.  The  ventricle  "escapes"  with  a  spontaneous  contrac- 
tion, as  if  impatient  of  waiting  longer  for  the  delayed  signal.  We 
may  assume  that  the  chemical  stimulus-material  accumulates  during 
the  prolonged  pause  and  finally  discharges  itself  in  a  contraction  inde- 
pendent of  the  ordinary  signal  from  above.  Like  many  of  the  newly 
discovered  cardiac  anomalies,  ventricular  escape  is  comparable  to 
insubordination  or  civil  war  in  the  heart.     It  is  recognized : 

(a)  In  part  by  the  fact  that  the  pause  following  it  in  the  arterio- 
gram is  "  compensatory,"  i.e.,  just  makes  up  for  the  shortening  of  the 
pause  before  the  premature  beat. 

(6)  Because  such  premature  beats  are  usually  weak  and  barely 
palpable  at  the  wrist,  while  the  succeeding  beat  is  unusually  strong — 
another  form  of  compensation. 

(c)  By  auscultation;  the  second  sound  is  often  found  to  be  absent, 
only  the  first  sound  is  heard. 

The  ventricular  origin  of  the  contraction  is  shown  by  the  fact 
that  the  venous  curve  from  the  jugular  exhibits  a  regular  uninterrupted 
rhythm  of  auricular  waves. 

2.  Auricular. — ^Premature  contractions  arising  in  the  auricle  and 
leading  to  a  similarly  premature  ventricular  beat  are  more  commonly 
seen  than  "ventricular  extrasystoles."  The  pause  following  such  a 
beat  may  be  compensatory  in  the  sense  explained  above,  but  usually 
it  is  not  so.  This  fact  and  the  presence  in  the  phlebogram  of  one 
auricular  wave  preceding  each  ventricular  wave  enable  us  to  recognize 
the  premature  beat  as  auricular  in  origin. 

The  electrocardiogram  shows  that  these  abnormal  beats  do  not 
arise  at  the  pace-maker,  but  from  some  other  part  of  the  auricle— 
another  example  of  cardiac  civil  war  or  uncoordinated  independent 
action  by  a  portion  of  the  heart  muscle.  In  the  same  way  the  ven- 
tricular extrasystoles  are  shown  to  arise  from  some  abnormally  active 
bit  of  ventricular  muscle. 


ARTERIOGRAMS,  PHLEBOGRAMS,  AND  ELECTROCARDIOGRAMS      119 

3.  The  clinical  significance  of  premature  beats  is  not  yet  clear. 
MacKenzie  believes  that  they  have  little  or  no  importance  either  in 
diagnosis  or  prognosis.  In  many  cases  they  certainly  represent  one 
of  the  mildest  and  most  harmless  types  of  arrhythmia,  but  whether 
this  is  always  true  is  not  yet  clear. 

Coupling  of  the  Heart  Beats  and  Alternation. 

In  uncompensated  heart  disease  of  any  type,  when  the  auricle  is 
fibrillating,  coupling  of  the  ventricular  beats  often  follows  the  ad- 
ministration of  digitalis.  Indeed,  in  the  vast  majority  of  cases  we 
can  assume  that  the  patient  has  recently  been  taking  digitalis  if  we 
find  the  beats  coming  in  close-knit  pairs  with  pauses  of  varying 
lengths  between  the  pairs.  Other  types  of  coupling  also  occur,  but 
will  not  be  mentioned  here. 

Alternation. — In  the  healthy  but  overtaxed  and  rapidly  beating 
heart,  in  many  cases  of  paroxysmal  tachycardia,  and  in  the  myocardial 
insufficiency  of  the  senile  heart,  one  may  find  a  regular  alternation 
of  strong  and  weak  beats  with  or  without  a  disturbance  of  rhythm. 
An  auricular  beat  precedes  each  ventricular  beat  in  normal  fashion. 
The  electrocardiogram  is  of  the  normal  type. 

The  weak  beat  may  appear  faintly  or  not  at  all  in  the  arterio- 
gram; a  powerful  apex  impulse  may  correspond  either  with  the  strong 
or  the  weak  pulse  beat  in  the  alternation.  It  is  always  a  serious 
symptom  and  means  that  "the  heart  muscle  is  in  a  precarious  condi- 
tion, be  it  structural  or  functional."      (Lewis,  loc.  cit.,  p.  278). 


CHAPTER  VII. 

PERCUSSION. 

I.  Technique. 

There  is  no  other  method  of  physical  examination  which  needs 
so  much  practice  as  percussion,  and  none  that  is  so  seldom  thor- 
oughly learned.  Many  physicians  never  succeed  in  acquiring  a 
facility  in  the  use  of  it  sufficient  to  make  them  rely  upon  their  results. 
Undoubtedly  one  of  the  greatest  difficulties  arises  from  the  necessity 
of  being  at  once  active  and  passive — at  once  the  percussor  and  the 
one  who  listens  to  the  percussion.  Students  half  unconsciously  get 
to  treat  the  percussion  as  an  end  in  itself,  and  hammer  away  indus- 
triously without  realizing  that  two-thirds  of  the  attention  must  be 
given  to  listening,  while  the  percussion  itself  should  become  semi- 
automatic. 

It  is  undoubtedly  an  advantage  to  possess  a  musical  ear,  but  this 
is  by  no  means  a  necessity.  Some  of  the  most  accurate  percussors 
that  I  know  possess  absolutely  no  musical  ear — no  ear,  that  is,  for 
pitch — and  form  their  judgments  in  percussing  upon  the  quality  or 
intensity  of  the  note,  and  upon  the  sense  of  resistance. 

In  this  country  practically  all  percussion  is  done  with  the  fin- 
gers; in  Germany  instruments  are  still  used  to  a  considerable  extent. 

(a)   Mediate  and  Immediate  Percussion. 

Percussion  may  be  either  "mediate"  or  "immediate,"  the  lat- 
ter term  referring  to  blows  struck  directly  upon  the  chest  with  the 
flat  of  the  hand,  or  upon  the  clavicles  with  the  tip  of  the  second 
finger. 

Methods. 

Mediate  percussion   (which  is  used  ninety-nine  hundredths  of  the 
time)  is  performed  as  follows : 

The  patient  should  either  lie  down  or  sit  with  his  back  against 
some  support.  The  reason  of  this  is  that  for  good  percussion  one 
needs  to  press  very  firmly  with  the  middle  finger  of  the  left  hand 

120 


PERCUSSION 


121 


upon  the  surface  of  the  chest,  so  firmly  that  if  the  patient  is  sitting 
upon  a  stool  without  support  for  his  back,  it  will  need  considerable 
exertion  upon  his  part  to  avoid  losing  his  balance. 

In  percussing  the  front  of  the  chest  it  is  important  to  have  the 
patient  sitting  or  lying  in  a  symmetrical  position — that  is,  without 
any  twist   or  tilting  to   one  side.     His  head   should  point  straight 


Fig.  95. — Position  of  the  Hands  When  Percussing  the  Right  Apex. 


forward  and  his  imisdes  must  he  thoroughly  relaxed.  Many  pa- 
tients, when  stripped  for  examination,  swell  out  their  chests  and 
sit  up  with  a  military  erectness.  The  muscular  tension  thus  pro- 
duced modifies  the  percussion  note  and  causes  an  embarrassing 
multitude  of  muscle  sounds  which  greatly  disturb  auscultation. 

Having  placed  the  patient  in  an  easy  and  symmetrical  position, 
our  percussion  should  proceed  according  to  the  following  rules : 

(i)   Always  press  as  firmly  as  possible  upon  the  surface  of  the 


122 


PHYSICAL  DIAGNOSIS 


Fig.  96. — Position  of  the  Hands  When  Percussing  the  Left  Apex. 


Fig.  97. — The  Right  Way  to  Percuss— ?.e.,  From  the  Wrist. 


PERCUSSION  123 

chest  with  the  second  finger  of  the  left  hand^  on  the  dorsum  of  which 
the  blow  is  to  be  struck.  Raise  the  other  fingers  of  the  left  hand  from 
the  chest  so  as  not  to  interfere  with  its  vibrations. 

(2)  Strike  a  quick,  perpendicular,  rebounding  blow  with  the  tip 
of  the  second  finger-  of  the  right  hand  upon  the  second  finger  of  the 
left  just  behind  the  nail,  imitating  as  far  as  possible  with  the  right 


Fig.  98. — The  Wrong  Way  to  Percuss — i.e.,  From  the  Elbow. 

hand  the  action  of  a  piano-hammer.  The  quicker  the  percussing 
finger  gets  away  again  after  striking,  the  clearer  will  be  the  note 
obtained. 

(3)   Let  all  the  blows  struck  in  any  one  part  of  the  chest  be  uni- 
form in  force. 

^  Left-handed  percussors  will,  of  course,  keep  the  right  hand  upon  the  chest  and  strike 
with  the  left. 

^  When  percussing  the  right  apex  I  prefer  to  strike  upon  the  thumb  (see  Figs.  95  and  96) 
as  it  is  almost  impossible  when  standing  directly  in  front  of  the  patient  to  fit  any  of  the 
fingers  comfortably  into  the  right  supraclavicular  fossa. 


124 


PHYSICAL  DIAGNOSIS 


(4)  Strike  from  the  wrist  and  not  from  the  elbow  (see  Figs.  97 
and  98) .     The  wrist  must  be  held  perfectly  loose. 

(5)  Keep  the  percussing  finger  bent  at  a  right  angle  as  in  Fig.  99. 
The  force  to  be  used  in  percussion  depends  upon  the  piu-pose 

for  which  the  percussion  is  used — that  is,  upon  what  organ  we  are 
percussing — and  also  upon  the  thickness  of  the  muscles  covering 
that  part  of  the  chest.  For  example,  it  is  necessary  to  percuss  very 
strongly  when  examining  the  back  of  a  muscular  man,   where  an 


Fig.  99. — Proper  Position  of  the  Right  Hand  During  Percussion. 


inch  or  two  of  muscle  intervenes  between  the  finger  on  which  we 
strike  and  the  lung  from  which  we  desire  to  elicit  a  sound.  Over 
the  front  of  the  chest  and  in  the  axillae  the  muscular  covering  is 
much  thinner,  and  hence  a  lighter  blow  suffices.  In  children  or 
emaciated  patients,  or  in  any  case  in  which  the  muscular  develop- 
ment is  slight,  percussion  should  be  as  light  as  is  sufficient  to  elicit  a 
clear  sound.  Heavy  percussion  is  sometimes  necessary  but  always 
unsatisfactory,  in  that  the  sound  which  it  elicits  comes  from  a  rela- 
tively large  area  of  the  chest  and  does  not  therefore  give  us  infor- 
mation about  the  condition  of  any  sharply  localized  area.     If  a  car- 


PERCUSSION 


125 


penter,  in  tapping  the  wall  to  find  the  position  of  the  studs,  strikes 
too  hard,  he  will  fail  to  find  the  beam,  because  the  blow  delivered 
over  the  spot  behind  which  the  beam  is  situated  is  so  forcible  as  to 
bring  out  the  resonance  of  the  hollow  parts  around.  It  is  the  same 
with  medical  percussion.  Heavy  percussion  is  always  inaccurate.^ 
It  may  be  necessary  where  the  muscles  are  very  thick,  but  its  value 
is  then  proportionately  diminished.  On  the  other  hand,  it  is  pos- 
sible to  strike  so  lightly  that  no  recognizable  sound  is  elicited  at 


Fig.   ioo. — Proper  Position  of  the  Patient  During  Percussion  of  the  Back. 


all.  The  best  percussion,  therefore,  is  that  which  is  just  forcible 
enough  to  elicit  a  clear  sound  without  setting  a  large  area  of  chest 
wall  in  vibration. 

The  position  of  the  patient  above  described  applies  to  percus- 
sion of  the  front.  When  we  desire  to  percuss  the  back,  it  is  im- 
portant to  get  the  scapulae  out  of  the  way  as  far  as  possible,  since 
we  cannot  get  an  accurate  idea  of  sounds  transmitted  through  them. 
To  accomplish  this,  we  put  the  patient  in  the  position  shown  in 
Fig.  IOO,  the  arms  crossed  upon  the  chest  and  each  hand  upon  the 
opposite    shoulder.     The  patient  should  be  rnade  to  bend   forward; 

^  See  also  below,  page  135,  the  lung  reflex. 


126 


PHYSICAL  DIAGNOSIS 


otherwise  the  left  hand  of  the  percussor  will  be  uncomfortably  bent 
backward  and  his  attention  thereby  distracted  (see  Fig.  loi). 

When  the  axillae  are  to  be  percussed,  the  patient  should  put  the 
hands  upon  the  top  of  the  head. 

(b)  Auscultatory  Percussion. 

If  while  percussing  one  auscults  at  the  same  time,   letting  the 
chest  piece  of  the  stethoscope  rest  upon  the  chest,   or  getting  the 


Fig.   ioi. — Wrong  Position  for  Percussing  the  Back.     The  patient  should  be  bent  forward. 


patient  or  an  assistant  to  hold  it  there,  the  sounds  produced  by 
percussion  are  greatly  intensified,  and  changes  in  their  volume, 
pitch,  or  quality  are  very  readily  appreciated.  The  blows  must  be 
very  lightly  struck,  either  upon  the  chest  itself  or  upon  the  finger 
used  as  a  pleximeter  in  the  ordinary  way.  Some  observers  use  a 
short  stroking  or  scratching  touch  upon  the  chest  itself  without 
employing  any  pleximeter. 


PERCUSSION  127 

This  method  is  used  especially  in  attempting  to  map  out  the 
borders  of  the  heart  and  in  marking  the  outlines  of  the  stomach. 
In  the  hands  of  skilled  observers  it  often  yields  valuable  results, 
but  one  source  of  error  must  be  especially  guarded  against.  The 
line  along  which  we  percuss,  when  approaching  an  organ  whose  bor- 
ders we  desire  to  mark  out,  'must  neither  approach  the  chest  piece  of 
the  stethoscope  nor  recede  from  it.  In  other  words,  the  line  along 
which  we  percuss  must  always  describe  a  segment  of  a  circle  whose 
centre  is  the  chest  piece  of  the  stethoscope  (see  Fig.  102).  If  we 
percuss,  as  we  ordinarily  do,  in  straight  lines  toward  or  away  from  the 
border  of  an  organ,   our  results   are  wholly  unreliable  since  every 


Percussion  arc. 


Chest  piece  of 

Stethoscope. 


Fig.  102. — Auscultatory  Percussion,  Showing  ttie  Arc  along  which  such  Percussion  should 

be  made. 

straight  line  must  bring  the  point  percussed  either  closer  to  the 
stethoscope  or  farther  from  it,  and  the  intensity  and  quality  of  the 
sounds  conducted  through  the  instrument  to  our  ears  vary  directly 
with  its  distance  from  the  point  percussed. 

It  will  be  readily  seen  that  the  usefulness  of  auscultatory  per- 
cussion is  limited  by  this  source  of  error,  and  that  considerable 
practice  is  necessary  before  one  can  get  the  best  results  from  this 
method.  Nevertheless  it  has,  I  believe,  a  place,  though  not  a  very 
important  one,  among  serviceable  methods  of  physical  examination. 

(c)  Palpatory  Percussion. 

■  Some  German   observers  use  a  method  of  percussion  in  which 
attention  is  fixed  directly  or  primarily  on  the  amount  of  resistance 


128 


PHYSICAL  DIAGNOSIS 


offered  by  the  tissues  over  which  percussion  is  made.  Even  in  or- 
dinary percussion  the  amount  of  resistance  is  always  noted  by  expe- 
rienced percussors,  but  the  element  in  sound  is  usually  the  main 
object  of  attention.  Palpatory  percussion  is  rather  a  series  of  short 
pushes  against  various  points  on  the  chest  wall,  but  some  sound  is 
elicited  and  probably  enters  into  the  rather  complex  judgment 
which  follows. 

In  this  country  palpatory  percussion  is  but  little  employed. 

Some  physicians  use  a  bit  of  flexible  rubber  for  direct  percussion, 
but  I  have  seen  no  advantage  gained  by  it. 


Normal  dulness  of 
the  right  apex. 


Liver  dulness. 


Liver  flatness. 


Deep  cardiac 
dulness. 


Superficial  cardiac 
dulness. 


Traube's  semilunar 
tympanitic  space. 


Fig.   103. — Percussion  Outlines  in  the  Normal  Chest. 

II.  Percussion  Resonance  of  the  Normal  Chest. 

The  note  obtained  by  percussing  the  normal  chest  varies  a  great 
deal  in  different  areas.  In  Fig.  103,  the  parts  shaded  darkest  are 
those  that  normally  give  least  sound  when  percussed  in  the  manner 
described  above,  while  from  the  lightest  areas  the  loudest  and  clear- 
est sound  may  be  elicited. 

(a)    Vesicular  Resonance. 

The  sound  elicited  in  the  latter  areas  is  known  as  normal  or 
''vesicular''  resonance,  and  is  due  to  the  presence  of  a  normal  amount 
of  air  in  the  vesicles  of  the  lung  underneath.  If  this  air-containing 
lung  is  replaced  by  a  fluid  or  solid  medium,  as  in  pleuritic  effusion 
or  pneumonia,  it  is  much  more  difficult  to  elicit  a  sound,  and  such 
sound  as  is  produced  is  short,  high  pitched,  and  has  a  feeble  carrying 
power  when  compared  with  the  sound  elicited  from  the  normal  lung. 
This  short,  feeble,  high-pitched  sound  is  known  technically  as  a  "  dull" 


PERCUSSION 


129 


or  "flat"  sound,  flatness  designating  the  extreme  of  the  quaHties  that 
characterize  dulness.  Over  the  parts  shaded  dark  in  Fig.  103,  we 
normally  get  a  dull  or  flat  tone,  the  darkest  portions  being  flat  and 
the  others  dull.  The  heavy  shadow  on  the  right  corresponds  to  the 
position  occupied  by  the  liver,  or  rather  by  that  part  of  it  which  is  in 
immediate  contact  with  the  chest  wall.  The  upper  portion  of  the 
liver  is  overlapped  by  the  right  lung  (see 
Fig.  103),  and  hence  at  this  point  we  get 
a  certain  amount  of  resonance  on  percus- 
sion, although  the  tone  is  not  so  clear  as 
that  to  be  obtained  higher  up.  Below 
the  sixth  rib  we  find  true  flatness  near  the 
sternum  and  for  a  few  inches  to  the  right 
of  this  point.  As  we  go  toward  the  axilla, 
the  line  of  lung  resonance  slopes  down,  as 
is  seen  in  Fig.  104.  In  the  back  resonance 
extends  to  the  ninth  or  tenth  ribs. 

{b)   Normal  Dull  Areas. 

On  the  left  side,  the  main  dull  area 
corresponds  to  the  heart,  which  at  this 
point  approaches  the  chest  wall,  and  over 
the  portion  shaded  darkest  is  uncovered 
by  the  lung.  The  part  here  lightly  shaded 
corresponds  to  that  portion  of  the  heart 
which  is  overlapped  by  the  margin  of  the 
right  and  left  lungs. 

Over  the  portion  of  the  heart  not  over- 
lapped by  the  lung  (see  Fig.  103,  p.  128)  the  percussion  note  is  nearly 
flat  to  light  percussion,  and  very  dull  even  when  strongly  percussed. 
This  little  quadrangular  area  is  known  as  the  "superficial  cardiac 
space,"  and  the  dulness  corresponding  to  it  is  referred  to  as  the 
"superficial"  cardiac  dulness,  while  the  dulness  corresponding  to  the 
outlines  of  the  heart  itself  beneath  the  overlapping  lung  margins  is 
called  the  "deep"  cardiac  dulness. 

When  the  heart  becomes  enlarged,  both  of  these  areas,  the  deep 
and  the  superficial,  are  enlarged,  the  former  corresponding  to  the 
increased  size  of  the  heart  itself,  while  the  superficial  cardiac  space 
is  extended  because  the  margins  of  the  lungs  are  pushed  aside  and 
a  larger  piece  of  the  heart  wall  comes  in  contact  with  the  chest  wall. 
9 


Fig.  104. — Position  of  the  Left 
Lung  in  the  Axilla. 


130  PHYSICAL  DIAGNOSIS 

Accordingly,  either  the  superficial  or  the  deep  dulness  may  be  mapped 
out  as  a  means  of  estimating  the  size  of  the  heart.  Each  method 
has  its  advantages  and  its  advocates.  The  superficial  dulness  is 
easier  to  map  out,  but  varies  not  only  with  the  size  of  the  heart, 
but  with  the  degree  to  which  the  lungs  are  distended  with  air,  or 
adherent  to  the  pericardium  or  chest  wall.  What  we  are  percussing 
is  in  fact  the  borders  of  the  lungs  at  this  point. 

On  the  other  hand,  the  deep  cardiac  dulness  is  much  more  satis- 
factory as  a  means  of  estimating  the  size  of  the  heart,  but  much 
more  difficult  to  map  out.  It  needs  a  trained  ear  and  long  practice 
to  percuss  out  correctly  the  borders  of  the  heart  itself,  especially 
the  right  and  the  upper  borders,  since  here  we  have  to  percuss  over 
the  sternum  where  differences  of  resonance  are  very  deceptive  and 
difficult  to  perceive. 

It  is  a  disputed  point  whether  light  or  forcible  percussion  should 
be  used  when  we  attempt  to  map  out  the  deep  cardiac  dulness. 
Heavy  percussion  is  believed  by  its  advocates  to  penetrate  through 
the  overlapping  lung  margins  and  bring  out  the  note  corresponding 
to  the  heart  beneath,  a  note  which,  they  say,  is  missed  altogether 
by  light  percussion.  On  the  other  hand,  those  who  employ  light 
percussion  contend  that  heavy  percussion  sets  in  vibration  so  large 
an  area  of  lung  superficially  that  fine  distinctions  of  note  are  made 
impossible  (see  above,  p.  124). 

Good  observers  are  to  be  found  on  each  side  of  this  question, 
and  I  have  no  doubt  that  either  method  works  well  in  skilled  hands. 
Personally  I  have  found  light  percussion  preferable. 

Whatever  method  we  use  we  must  percuss  successive  points 
along  a  line  running  at  right  angles  to  the  border  of  the  organ  which 
we  wish  to  outline  until  a  change  of  note  is  perceived.  Thus,  if  we 
wish  to  percuss  out  the  upper  border  of  the  liver,  we  strike  successive 
points  along  a  line  running  parallel  to  the  sternum  and  about  an 
inch  to  the  right  of  it.^  When  a  change  of  note  is  perceived,  the 
point  should  be  marked  with  a  skin  pencil;  then  we  percuss  along  a 
line  parallel  to  the  first  one,  and  perhaps  an  inch  farther  out,  and 
again  mark  with  a  dot  the  point  at  which  the  note  first  changes.  A 
line  connecting  the  points  so  marked  upon  the  skin  represents  the 
border  of  the  organ  to  be  outlined. 

If  now  we  look  at  the  upper  part  of  the  chest  in  Fig.  103,  we  notice 
at  once  that  the  two  sides  are  not  shaded  alike:  the  left  apex  is  dis- 

^  Or  we  may  reverse  the  procedure;  percuss  first  over  the  Uver  and  then  work  toward 
the  luner  above  until  the  note  becomes  more  resonant. 


PERCUSSION  131 

tinctly  lighter  colored  than  the  right.  This  is  a  very  important 
point  and  one  not  sufficiently  appreciated  by  students.  The  apex 
of  the  normal  right  lung  is  distinctly  less  resonant  than  the  apex  of 
the  left  in  a  corresponding  position. 

In  percussing  at  the  bottom  of  the  left  axilla,  we  come  upon  a 
small  oval  area  of  dulness  corresponding  to  that  outlined  in  Fig.  104. 
This  is  the  area  of  splenic  dulness,  so  called,  and  corresponds  to  that 
portion  of  the  spleen  which  is  in  contact  with  the  chest  wall.  This 
dull  area  is  to  be  made  out  only  in  case  the  stomach  and  colon  are  not 
overdistended  with  air.  When  these  organs  are  full  of  gas  as  is  not 
infrequently  the  case,  there  is  no  area  of  splenic  dulness  and  the  whole 
region  gives  forth,  when  percussed,  a  note  of  a  quality  next  to  be 
described,  namely,  "tympanitic.''  In  my  experience,  percussion  of  the 
spleen  is  of  very  little  use  when  we  want  it  most,  i.e.,  in  infectious 
diseases  like  typhoid,  malaria  or  sepsis.  If  the  edge  of  the  organ 
can  be  felt  it  is  almost  always  enlarged ;  if  the  edge  cannot  be  felt  the 
results  of  percussion  are  most  unreliable.  In  leucaemia  and  other 
diseases  which  greatly  enlarge  the  spleen  we  can  accurately  percuss 
out  its  upper  border,  but  this  has  little  practical  value. 

(c)   Tympanitic  Resonance. 

Tympanitic  resonance  is  that  obtained  over  a  hollow  body, 
like  the  stomach  when  moderately  distended  with  air.^  It  is  usu- 
ally of  a  higher  pitch  than  the  resonance  to  be  obtained  over  the 
normal  lung,  and  may  be  elicited  by  percussion  lighter  than  that 
needed  to  bring  out  the  lung  resonance.  It  differs  also  from  the 
vesicular  or  pulmonary  resonance  in  quality,  in  a  way  easy  to  appre- 
ciate but  difficult  to  describe.  Tympanitic  resonance  is  usually  to 
be  heard  when  one  percusses  over  the  front  of  the  left  chest  near 
the  ensiform  cartilage  and  for  a  few  inches  to  the  left  of  this  point 
over  the  area  corresponding  with  that  of  the  stomach  more  or  less 
distended  with  air.  This  tympanitic  area,  known  as  "Traube's 
semilunar  space,"  varies  a  great  deal  in  size  according  to  the  contents 
of  the  stomach.  It  is  bounded  on  the  right  by  the  liver  flatness, 
above  by  the  pulmonary  resonance,  on  the  left  by  the  splenic  dul- 
ness, and  below  by  the  resonance  of  the  intestine,  which  is  also 
tympanitic,  although  its  pitch  is  different  owing  to  the  different 
size  and  shape  of  the  intestine. 

(The  right  axilla  shows  normal  lung  resonance  down  to  the  point 
at  which  the  liver  flatness  begins,  as  shown  in  Fig.  103.) 

^  Extreme  distention  here,  as  in  a  snare  drum,  is  associated  with  a  dull  percussion  note 
(see  below  p.  309). 


132  PHYSICAL  DIAGNOSIS 

In  the  back,  when  the  scapulae  are  drawn  forward,  as  shown  in  Fig. 
loo,  page  125,  percussion  eUcits  a  clear  vesicular  resonance  from  top  to 
bottom  on  each  side,  although  the  top  of  the  right  lung  is  always 
slightly  less  resonant  than  the  top  of  the  left,  and  sometimes  the  bot- 
tom of  the  right  lung  is  slightly  less  resonant  than  the  corresponding 
portion  of  the  left,  on  account  of  the  presence  of  the  liver  on  the  right. 

It  should  be  remembered,  however,  that  in  the  majority  of  cases 
the  resonance  throughout  the  back  is  distinctly  less  than  that  obtained 
over  the  front,  on  account  of  the  greater  thickness  of  the  back  muscles. 
Yet  in  children  or  emaciated  persons,  or  where  the  muscular  develop- 
ment is  slight,  there  may  be  as  much  resonance  behind  as  in  front. 

Importance  of  Percussing  Symmetrical  Points. — Since  we  depend 
for  our  standard  of  resonance  upon  comparison  with  a  similar  spot 
on  the  outside  of  the  chest,  it  is  all-important  that  in  making  such 
comparisons  we  should  percuss  symmetrical  points,  and  not,  for 
example,  compare  the  resonance  over  the  third  rib  in  the  right  front 
with  that  over  the  third  interspace  on  the  left,  since  more  resonance 
can  always  be  elicited  over  an  interspace  than  over  a  rib.  This 
comparison  of  symmetrical  points,  however,  is  interfered  with  by 
the  presence  of  the  heart  on  one  side  and  the  liver  on  the  other,  as 
well  as  by  the  fact  that  the  apex  of  the  right  lung  is  normally  less 
resonant  than  that  of  the  left.  A  resonance  which  would  be  patho- 
logically feeble  if  obtained  over  the  left  top  may  be  normal  over  the 
right.  Where  both  sides  are  abnormal,  as  in  bilateral  disease  of 
the  lung,  or  where  fluid  accumulates  in  both  pleural  cavities,  we 
have  to  make  the  best  comparison  we  can  between  the  sound  in  the 
given  case  and  an  ideal  standard  carried  in  the  mind. 

It  must  always  be  remembered  that  the  amount  of  resonance 
obtained  at  any  point  by  percussion  depends  upon  how  hard  one 
strikes,  as  well  as  upon  the  conditions  obtaining  within  the  chest. 
A  powerful  blow  over  a  diseased  lung  may  bring  out  more  resonance 
than  a  lighter  blow  over  a  normal  lung.  To  strike  with  perfect 
fairness  and  with  equal  force  upon  each  side  can  be  learned  only  by 
considerable  practice.  Furthermore,  the  distance  from  the  ear  to 
each  of  the  two  points,  the  resonance  of  which  we  are  comparing,  must 
be  the  same — that  is,  we  must  stand  squarely  in  front  or  squarely 
behind  the  patient,  otherwise  the  note  coming  from  the  part  farther 
from  the  ear  will  sound  duller  than  that  coming  from  the  nearer 
side. 

The  normal  resonance  of  the  different  parts  of  the  chest  can  be 
considerably  modified  by  the  position  of  the  patient,  by  deep  breathing, 


PERCUSSION  133 

by  muscular  exertion,  and  by  other  less  important  conditions.  If, 
for  example,  the  patient  lies  upon  the  left  side,  the  heart  swings  out 
toward  the  left  axilla  and  its  dulness  is  extended  in  the  same  direction. 
Deep  inspiration  distends  the  margins  of  the  lungs  so  that  they 
encroach  upon  and  reduce  the  area  of  the  heart  dulness  and  liver 
dulness.  After  muscular  exertion  the  lungs  become  more  than 
ordinarily  voluminous,  owing  to  the  temporary  distention  brought 
about  by  the  unusual  amount  of  work  thrown  upon  them. 

The  area  of  cardiac  dulness  is  increased  in  any  condition  involving 
insufficient  lung  expansion.  Thus,  in  children,  in  debility,  chlorosis, 
or  fevers,  the  space  occupied  by  the  lungs  is  relatively  small  and  the 
dull  areas  corresponding  to  the  heart  and  liver  are  proportionately 
enlarged.  In  old  age,  on  the  other  hand,  when  the  lungs  have  lost 
part  of  their  elasticity  and  sag  down  over  the  heart  and  liver,  the 
percussion  dulness  of  these  organs  is  reduced. 

Conditions  Modifying  the  Percussion  Note  in  Health. — The  develop- 
ment of  muscle  or  fat  as  well  as  the  thickness  of  the  chest  wall  will 
influence  greatly  the  amount  of  resonance  to  be  obtained  by  percussion. 
Indeed,  we  see  now  and  then  an  individual  in  no  part  of  whose  chest 
can  any  clear  percussion  tone  be  elicited.  In  women,  the  amount  of 
development  of  the  breasts  has  also  great  influence  upon  the  percussion 
note.  In  children,  the  note  is  generally  clearer,  and  only  the  lightest 
percussion  is  to  be  used  on  account  of  the  thinness  of  the  chest  wall. 
In  old  people  whose  lungs  are  almost  always  more  or  less  emphyse- 
matous, a  shade  of  tympanitic  quality  is  added  to  the  normal  vesicular 
resonance.  The  distention  of  the  colon  with  gas  may  obliterate  the 
liver  dulness  by  rotating  that  organ  so  that  only  its  edge  is  in  contact 
with  the  chest  wall,  and  if  there  is  wind  in  the  stomach,  a  variable 
amount  of  tympany  is  heard  on  percussing  the  lower  left  front  and 
axilla  or  even  in  the  left  back. 

If  a  patient  is  examined  while  lying  on  the  side  the  amount  of 
resonance  over  the  lung  corresponding  to  the  side  on  which  he  lies 
is  usually  less  than  that  of  the  side  which  is  uppermost,  because  there 
is  more  air  in  the  latter.^  Whatever  the  patient's  position,  the 
amount  of  resonance  is  also  greater  at  the  end  of  inspiration  than 
at  the  end  of  expiration,  for  the  reason  just  given.  As  the  -lungs 
expand  with  full  inspiration,  their  borders  must  move  so  as  to  cover  a 
larger  portion  of  the  organs  which  they  normally  overlap.  Portions 
of  the  chest  which  at  the  end  of  expiration  are  dull  or  flat,  owing 

^  There  is  also  a  shade  of  tympany  associated  with  the  dulness  of  the  feebly  expanded 
lung  of  the  lower  side. 


134  PHYSICAL  DIAGNOSIS 

to  the  close  juxtaposition  of  the  heart,  Hver,  or  spleen,  become 
resonant  at  the  end  of  inspiration.  For  example,  the  lower  margin 
of  the  right  lung  moves  down  during  inspiration  so  as  to  cover  a 
considerably  larger  portion  of  the  liver. 

Percussion  as  a  Means  of  A  scertaining  the  Movahility  of  the  Lung 
Borders. — -It  is  sometimes  of  importance  to  determine  not  merely 
the  position  of  the  resting  lung  but  its  power  to  expand  freely.  This 
can  be  ascertained  by  percussion  in  the  following  way:  The  lower 
border  of  the  lung  resonance,  say  in  the  axilla,  is  carefully  marked 
out.  Then  percussion  is  made  over  a  point  just  helow  the  level  of 
the  resting  lung  and  at  the  same  time  the  patient  is  directed  to  inspire 
deeply.  If  the  lung  expands  and  its  border  moves  down,  the  percussion 
note  will  change  suddenly  from  dull  to  resonant  during  the  inspiration. 
An  excursion  of  two  or  three  inches  can  often  be  demonstrated  by 
this  method,  which  is  especially  important  for  the  anterior  and  posterior 
margins  of  the  lung.  In  the  axilla  Litten's  phrenic  shadow  will  give 
us  the  same  information. 

The  mobility  of  the  borders  of  the  lung,  as  determined  by  this 
method,  is  of  considerable  clinical  importance,  for  an  absence  of 
such  mobility  may  indicate  pleuritic  adhesions.  Its  amount  depends 
upon  various  conditions  and  varies  much  in  different  individuals,  but 
complete  absence  of  mobility  is  always  pathological. 

(  d)    Cracked-pot  Resonance. 

When  percussing  the  chest  of  a  crying  child,  we  sometimes  notice 
that  the  sound  elicited  has  a  peculiar  "chinking"  quality,  like  that 
produced  by  striking  one  coin  with  another,  but  more  muffled.  The 
sound  may  be  more  closely  imitated,  and  the  mode  of  its  production 
illustrated,  by  clasping  the  hands  palm  to  palm  so  as  to  enclose  an 
air  space  which  communicates  with  the  outer  air  through  a  chink 
left  open,  and  then  striking  the  back  of  the  under  hand  against  the 
knee.  By  the  blow,  air  is  forced  out  through  the  chink  with  a  sound 
like  that  of  metallic  coins  struck  together. 

In  disease,  the  cracked-pot  sound  is  usually  produced  over  a 
pulmonary  cavity  (as  in  advanced  phthisis)  from  which  the  air  is 
suddenly  and  forcibly  expelled  by  the  percussion  stroke. 

It  is  much  easier  to  hear  this  peculiar  sound  if,  while  percussing, 
one  listens  with  a  stethoscope  at  the  patient's  open  mouth.  The 
patient  himself  holds  the  chest  piece  of  the  instrument  just  in  front 
of  his  open  mouth,  leaving  the  auscultator's  hands  free  for  percussing. 


PERCUSSION  135 

(e)   Amphoric  Resonance. 

A  low-pitched  hollow  sound  approximating  in  quality  to  tym- 
panitic resonance,  and  sometimes  obtained  over  pulmonary  cavities 
or  over  pneumothorax,  has  received  the  name  of  amphoric  resonance. 
It  may  be  imitated  by  percussing  the  trachea  or  the  cheek  when 
moderately  distended  with  air. 

Summary. 

The  varieties  of  resonance  to  be  obtained  by  percussing  the  normal 
thorax  are: 

(i)    Vesicular  resonance,  to  be  obtained  over  normal  lung  tissue. 

(2)  Tympanitic  resonance,  to  be  obtained  in  Traube's  semilunar 
space. 

(3)  Diminished  resonance  or  dulness,  such  as  is  present  over  the 
scapulse,  and 

(4)  Absence  of  resonance  or  flatness,  such  as  is  discovered  when 
we  percuss  over  the  lowest  ribs  in  the  right  front. 

(5)  Cracked-pot  resonance,  sometimes  obtainable  over  the  chest  of 
a  crying  child. 

(6)  Amphoric  resonance,  obtainable  over  the  trachea. 

Any  of  these  sounds  may  denote  disease  if  obtained  in  portions 
of  the  chest  where  they  are  not  normally  found.  Each  has  its  place, 
and  becomes  pathological  if  found  elsewhere.  Tympanitic  resonance  is 
normal  at  the  bottom  of  the  left  front  and  axilla,  but  not  elsewhere. 
Dulness  or  flatness  is  normal  over  the  areas  corresponding  to  the 
heart,  liver,  and  spleen,  and  over  the  scapulse,  but  not  elsewhere 
unless  the  muscular  covering  of  the  chest  is  enormously  thick.  Vesic- 
ular resonance  is  normal  over  the  areas  corresponding  to  the  lungs, 
but  becomes  evidence  of  disease  if  found  over  the  cardiac  or  hepatic 
areas. 

Cracked-pot  resonance  may  be  normal  if  produced  while  percussing 
the  chest  of  a  child,  but  under  all  other  conditions,  so  far  as  is  known, 
denotes  disease. 

Amphoric  resonance  always  means  disease,  usually  pulmonary 
cavity  or  pneumothorax,  if  found  elsewhere  than  over  the  trachea. 

'    (/)  The  Ltmg  Reflex. 

It  must  also  be  remembered,  when  percussing,  that  in  some  cases 
every  forcible  percussion  blow  increases  the  resonance  to  be  obtained 
by  subsequent  blows.     Any  one  who  has  demonstrated  an   area    of 


136  PHYSICAL  DIAGNOSIS 

percussion  dulness  to  many  students  in  succession  must  have  noticed 
occasionally  that  the  more  we  percuss  the  dull  area,  the  more  resonant 
it  becomes,  so  that  to  those  who  last  listen  to  the  demonstration  the 
difference  which  we  wish  to  bring  out  is  much  less  obvious  than  to 
those  who  heard  the  earliest  percussion  strokes.  Abrams  has  referred 
to  this  fact  under  the  name  of  the  "lung  reflex,"  believing,  partly 
on  the  evidence  of  fluoroscopic  examination,  that  if  an  irritant  such 
as  cold  or  mustard  is  applied  to  any  part  of  the  skin  covering  the 
thorax,  the  lung  expands  so  that  a  localized  temporary  emphysema 
is  produced  in  response  to  the  irritation.  Apparently  percussion  has 
a  similar  effect. 

III.  Sense  of  Resistance. 

While  percussing  the  chest. we  must  be  on  the  lookout  not  only 
for  changes  in  resonance,  but  for  variations  in  the  amount  of  resist- 
ance felt  underneath  the  flnger.  Normally  the  elasticity  of  the 
chest  walls  over  the  upper  fronts  is  considerably  greater  and  the 
sense  of  resistance  considerably  less  than  that  felt  over  the  liver. 
In  the  axillae  and  over  those  portions  of  the  back  not  covered  by 
the  scapulae,  we  feel  in  normal  chests  an  elastic  resistance  when 
percussing  which  is  in  contrast  with  the  dead,  woodeny  feeling 
which  is  communicated  to  the  finger  when  the  air-containing  lung 
is  replaced  by  fluid  or  solid  contents  (pleuritic  effusion,  pneumonia, 
phthisis,  etc.).  In  some  physicians  this  sense  of  resistance  is  very 
highly  developed  and  as  much  information  is  obtained  thereby  as 
through  the  sounds  elicited.  As  a  rule,  however,  it  is  only  by  long 
practice  that  the  sense  of  resistance  is  cultivated  to  a  point  where  it 
becomes  of  distinct  use  in  diagnosis. 


CHAPTER  VIII. 

AUSCULATION. 

Auscultation  may  be  practised  by  placing  one's  ear  directly 
against  the  patient's  chest  (immediate  auscultation)  or  with  the 
help  of  a  stethoscope  (mediate  auscultation) . 

Each  method  has  its  place.  Immediate  auscultation  is  said  to 
have  advantages  similar  to  those  of  the  low  power  of  the  micro- 
scope, in  that  it  gives  us  a  general  idea  of  the  condition  of  a  rela- 
tively large  area  of  tissue,  while  the  stethoscope  may  be  used,  like 
the  oil  immersion  lens,  to  bring  out  details  at  one  or  another  point. 

On  the  other  hand,  I  am  firmly  convinced  that  the  unaided  ear 
can  perceive  sounds  conducted  from  the  interior  of  the  lung — sounds 
quite  inaudible  with  any  stethoscope — and  that  in  this  way  the  faint 
tubular  breathing  produced  by  deep-seated  areas  of  solidified  lung 
may  be  recognized. 

Immediate  auscultation  may  be  objected  to: 

(a)  On  grounds  of  delicacy  (when  examining  persons  of  the  oppo- 
site sex). 

(6)  On  grounds  of  cleanliness  (although  the  chest  may  be  cov- 
ered with  a  towel  so  as  to  protect  the  auscultator  to  a  certain  extent) . 

(c)  Because  we  cannot  conveniently  reach  the  supraclavicular 
or  the  upper  axillary  regions  in  this  way. 

{d)  Because  it  is  difficult  to  localize  the  different  valvular  areas 
and  the  sites  of  cardiac  murmurs  if  immediate  auscultation  is 
employed. 

On  account  of  the  latter  objection  the  great  majority  of  observers 
now  use  the  stethoscope  to  examine  the  heart.  For  the  lungs,  both 
methods  are  employed  by  most  experienced  auscultators.  I  have 
already  mentioned  the  importance  of  immediate  auscultation  in  the 
search  for  deep-seated  areas  of  pneumonia.  Attention  has  also  been 
called  by  Conner  (Assoc,  of  American  Physicians,  1907,  p.  113)  to  the 
fact  that  the  diastolic  murmur  of  aortic  insufficiency  is  sometimes 
audible  to  the  unaided  ear  when  it  cannot  be  heard  with  any  form 

137 


138 


PHYSICAL  DIAGNOSIS 


of  Stethoscope.     Faint,  high-pitched  blowing  sounds  are  those  which 
the  free  ear  is  especially  adapted  to  detect. 

This  is  doubtless  due,  as  Conner  explains,  to  the  fact  that  the  tubes 
of  the  stethoscope  do  not  conduct  high-pitched  sounds  well.  With 
the  free  ear  we  have  also  the  opportunity  to  detect  the  bone-con- 
ducted sounds  which  are  missed  in  mediate  stethoscopic  auscultation. 

I.  Selection  of  a  Stethoscope. 

(i)  It  is  as  rash  for  any  one  to 
select  a  stethoscope  without  first 
trying  the  fit  of  the  ear  pieces  in 
his  ears  as  it  would  be  to  buy  a 
new  hat  without  trying  it  on. 
What  suits  A.  very  well  is  quite 
impossible  for  B.  It  is  true  that 
one  can  get  used  to  almost  any 
stethoscope  as  one  can  to  almost 
any  hat,  but  it  is  not  necessary  to 
do  so.  The  ear  pieces  of  the  ordi- 
nary stethoscope  are  often  too  small 
and  rarely  too  large.  In  case  of 
doubt,  therefore,  it  is  better  to  err 
upon  the  side  of  getting  a  stetho- 
scope with  too  large  rather  than 
too  small  ends. 

(2)  The  binaural  stethoscope, 
which  is  now  almost  exclusively 
used  in  this  country,  maintains  its 
position  in  the  ears  of  the  auscul- 
tator  either  through  the  pressure 
of  a  rubber  strap  stretched  around  the  metal  tubes 
leading  to  the  ears,  or  by  means  of  a  steel  spring 
connecting  the  tubes.  Either  variety  is  usually 
satisfactory,  but  I  prefer  a  stethoscope  made  with 
a  steel  spring  (see  Fig.  105)  because  such  a  spring 
is  far  less  likely  to  break  or  lose  its  elasticity  than 
a  rubber  strap.  A  rubber  strap  can  always  be 
added  if  this  is  desirable.  It  is  important  to  pick 
out  an  instrument  possessing  a  spring  not  strong 
enough  to  cause  pain  in  the  external  meatus  of  the  ear  and  yet 
strong  enough  to  hold  the  ear  pieces  firmly  in  place.      Persons  with 


Fig.  106. — Cam- 
man  Stethoscope 
With  Stiff  Tubing 
and  Rubber  Strap, 


Fig.  105. — Stetho- 
scope Fitted  with 
Long  Flexible 
Tubes,  Especially 
Useful  When  Ex- 
amining Children. 


AUSCULTATION 


139 


narrow   heads    need    a    much    more  powerful  spring  or   strap    than 
would  be  convenient  for  persons  with  wide  heads. 

(3)  The  rubber  tubing  used  to  join  the  metallic  tubes  to  the 
chest  piece  of  the  instrument  should  be  as  flexible  as  possible  (see 
Fig.  105).     Stiff  tubing  (see  Fig.  106)  makes  it  necessary  for  the  aus- 

cultator  to  move  his  head  and 

body  from  place  to  place  as 

the  examination  of  the  chest 

progresses,    while    if    flexible 

tubing  is  used  the  head  need 

seldom  be  moved  and  a  great 

deal   of   time   and   fatigue   is 

thus  saved.  Stiff  stetho- 
scopes are  especially  incon- 
venient when  examining  the 

axilla. 

(4)    Jointed    stethoscopes 

which  fold  up  or  take  apart 

should  be  scrupulously  avoid- 
ed.    They  are  a  delusion  and 

a  snare,  apt  to  come  apart  at 

critical  moments,  and  to  snap 

and  creak  at  the  joints  when 

in  use,   sometimes  producing 

in  this  way  sounds  which  may 

be  easily  mistaken  for  rales. 

Such    an    instrument    is    no 

more   portable   nor    compact 

than  the  ordinary  form  with 

flexible  tubes.  It  has,  there- 
fore, no  advantages  over  stethoscopes  made  in 
one  piece  and  possesses  disadvantages  which 
are  peculiarly  annoying. 

(5)  The  Chest  Piece. — The  majority  of  the  stethoscopes  now  in 
use  have  a  chest  piece  of  hard-rubber  or  wood  with  a  diameter  of 
about  seven-eighths  of  an  inch.  Chest  pieces  of  larger  diameter  than 
this  are  to  be  avoided  as  they  are  very  difficult  to  maintain  in  close 
apposition  with  thin  chests.  To  avoid  this  difficulty  the  chest  piece 
is  sometimes  made  of  soft-rubber  or  its  diameter  still  further  reduced. 

(6)  The  Bowles  Stethoscope. — (See  Figs.  107  and  108).  Within 
recent  years  there  has   been  introduced   an  instrument  which,   for 


Fig  .  107 . — B  owles' 
Stethoscope.  Front 
view. 


Fig.  108. — Combination 
Bowles'  Stethoscope. 


140  PHYSICAL  DIAGNOSIS 

many  purposes,  seems  to  me  far  superior  to  any  other  form  of  stetho- 
scope with  which  I  am  acquainted.  Its  pecuHarity  is  the  chest  piece, 
which  consists  of  a  very  shallow  steel  cup  (see  Fig.  109)  over  the 
mouth  of  which  a  thin  metal  plate  or  a  bit  of  pigskin  is  fastened. 
The  metal  or  pigskin  diaphragm  serves  simply  to  prevent  the  tissues 
of  the  chest  from  projecting  into  the  shallow  cup  of  the  chest  piece 
when  the  latter  is  pressed  against  the  chest,  and  does  not  in  any 
other  way  contribute  to  the  sounds  which  we  hear  with  the  instru 
ment.  This  is  proved  by  the  fact  that  we  can  hear  as  well  even 
when  the  diaphragm  is  cracked  across  in  several  directions. 

With  this  instrument  almost  all  sounds  produced  within  the  chest 
can  be  heard  much  more  distinctly  than  in  any  other  variety  of 
stethoscope.  Cardiac  murmurs  which  are  inaudible  with  any  other 
stethoscope  may  be  distinctly  heard  with  this.  Especially  is  this 
true  of  low-pitched  murmurs  due  to  aortic  regurgitation.  Yet  it  is 
useful  for  examination  not  merely  of  the  heart,  but  of  the  lungs  as  well. 


Fig.  109. — Chest  Piece  of  Bowles'  Stethoscope.  On  the  right  the  shallow  cup  communi- 
cating with  the  ear  tubes.  On  the  left  the  diaphragm  which  covers  the  cup,  and  the 
ring  which  holds  it  in  place. 


For  any  one  who  has  difficulty  in  hearing  the  ordinary  cardiac  or  respir- 
atory sounds,  or  for  one  who  is  partially  deaf,  the  instrument  is 
invaluable.  As  the  metal  rim  of  the  chest  is  apt  to  get  unpleasantly 
cold,  it  is  best  to  cover  it  with  a  bit  of  rubber  or  kid.  This  saves 
the  patient  some  discomfort  and  also  tends  to  prevent  the  instru- 
ment from  slipping  on  the  skin.  The  flat  chest  piece  makes  the 
instrument  very  useful  in  listening  to  the  posterior  portions  of  the 
lungs  in  cases  of  pneumonia  in  which  the  patient  is  too  sick  to  be 
turned  over  or  to  sit  up.     Without  moving  the  patient  at  all  we  can 


AUSCULTATION 


141 


work  the  chest  piece  in  under  the  back  of  the  patient  by  pressing 
down  the  bed-clothes,  and  in  this  way  can  listen  to  any  part  of 
the  chest  without  moving  the  patient.  A  further  advantage  of  the 
instrument  is  that  it  enables  us  to  gain  an  approximately  accurate 
idea  of  the  heart  sounds  without  undressing  the  patient.  Respira- 
tory sounds  cannot  well  be  listened  to  through  the  clothes,  as  the 
rubbing  of  the  latter  may  simulate  rales. 

There  are  two  purposes  for  which  I  have  found  the  Bowles  stetho- 
scope    inferior    to     the    ordinary 
stethoscope : 

(i)  For  listening  over  the  apex 
of  the  lung  for  fine  rales,  e.g.,  in 
incipient  phthisis. 

(2)  For  listening  for  superficial 
sounds,  such  as  a  friction  rub  or 
a  presystolic  murmur.^  When  I 
desire  to  listen  for  fine  rales  at  an 
apex,  for  a  friction  rub,  or  for  a 
presystolic  murmur,  I  separate  the 
chest  piece  of  the  Bowles  stetho- 
scope from  the  hard-rubber  bell 
into  which  it  is  inserted,  thereby 
converting  the  instrument  into  one 
of  the  ordinary  form.  With  an 
extra  hard-rubber  bell  attached, 
the  instrument  is  no  more  bulky 
than  an  ordinary  stethoscope,  and 
far  more  efi&cient.  When  used  for 
listening  to  the  respiration,  the 
Bowles  instrument  gives  us  infor- 
mation similar  in  some  respects  to  that  obtained  by  the  use  of  the 
free  ear — that  is,  we  are  through  it  enabled  to  ascertain  by  listening 
at  one  spot  the  condition  of  a  much  larger  area  of  the  chest  than 
can  in  any  other  way  be  investigated. 

Owing  to  the  fact  that  both  cardiac  and  respiratory  sounds  are 
magnified  by  the  Bowles  stethoscope,  this  instrument  is  especially 


Fig. 


no. — Bowles'  Multiple  Stethoscope 
for  Six  Students. 


^  It  has  frequently  been  observed,  when  listening  with  the  ordinary  stethoscope,  that 
a  presystoUc  murmur  can  be  better  heard  if  only  the  very  lightest  pressure  is  made  with 
the  stethoscope.  The  fact  that  a  thrill  is  communicated  to  the  chest  wall,  and  that  that 
thrill  is  connected  with  the  audible  murmur  explains  my  calUng  this  murmur  a  superficial 
one. 


142 


PHYSICAL  DIAGNOSIS 


well  adapted  for  use  with  some  sort  of  an  attachment  whereby  several 
sets  of  ear  pieces  are  so  jointed  by  tubing  to  one  chest  piece  that 
several  persons  may  listen  at  once.  Bowles'  multiple  stethoscope, 
fitted  for  six  and  for  twelve  observers,  is  seen  in  Figs,  i  lo  and  1 1 1,  and 
the  method  of  its  use  in  Fig.  112.  In  the  teaching  of  auscultation  this 
instrument  is  of  great  value,  saving  as  it  does  the  time  of  the  instruc- 
tor and  of  the  students  and  the  strength  of  the  patient.  The  sounds 
conducted  through  any  one  of  the  twelve  tubes  used  in  this  instrument 

are  as  loud  as  those  to 
be  heard  with  a  single 
instrument  of  the  ordi- 
nary form,  although  far 
fainter  than  those  to  be 
heard  with  a  single 
Bowles  stethoscope. 

II.    The   Use  of  the 
Stethoscope. 

Having  secured  an 
instrument  which  fits 
the  ears  satisfactorily, 
the  beginner  may  get  a 
good  deal  of  practice  by 
using  it  upon  himself, 
especially  upon  his  own 
heart.  The  chief  point 
to  be  learned  is  to  dis- 
regard various  irrelevant 
sounds  and  to  concen- 
trate attention  upon  those  which  are  relevant.  Almost  any  one  hears 
enough  with  a  stethoscope,  and  most  beginners  hear  too  much.  No 
great  keenness  of  hearing  is  required,  for  the  sounds  which  we 
listen  for  are  not,  as  a  rule,  difficult  to  hear  if  attention  is  concen- 
trated upon  them. 


Fig.  III. 


-Bowles'  Multiple  Stethoscope  for 
Twelve  Students. 


A.  Selective  Attention  and  What  to  Disregard. 


Accordingly,  the  art  of  using  a  stethoscope  successfully  depends 
upon  the  acquisition  of  two  powers — 

(a)   A  knowledge  of  what  to   disregard,      (b)   A  selective  atten- 


AUSCULTATION 


143 


tion  or  concentration  upon  those  sounds  which  we  know  to  be  of 
importance. 

Among  the  sounds  which  we  must  learn  to  disregard  are  the 
following : 

(i)  Noises  produced  in  the  room  or  its  immediate  neighborhood, 
but  not  connected  with  the  patient  himself.  It  is,  of  course,  easier 
to  listen  in  a  perfectly  quiet  room  where  there  are  no  external  noises 


Fig.  112. — Bowles'  Multiple  Stethoscope  in  Use.     Twelve  students  listening  at  once. 


which  need  to  be  excluded  from  attention,  but  as  the  greater  part 
of  the  student's  work  must  be  done  in  more  or  less  noisy  places,  it 
is  for  the  beginner  a  practical  necessity  to  learn  to  withdraw  his  atten- 
tion from  the  various  sounds  which  reach  his  ear  from  the  street, 
from  other  parts  of  the  building,  or  from  the  room  in  which  he  is 
working.  This  is  at  first  no  easy  matter,  but  can  be  accomplished 
with  practice. 

(2)    When  the  power  to  disregard  external  noises  has  been  ac- 
quired,  a  still  further  selection   must  be  made  among  the   sounds 


144  PHYSICAL  DIAGNOSIS 

which  come  to  the  ear  through  the  tubes  of  the  stethoscope.  Noises 
produced  by  friction  of  the  chest  piece  of  the  stethoscope  upon  the 
skin  are  especialty  deceptive  and  may  closely  simulate  a  pleural  or 
pericardial  friction  sound.  It  is  well  for  the  student  to  experiment 
upon  the  nature  and  extent  of  such  "skin  rubs"  by  deliberately 
moving  the  chest  piece  of  the  stethoscope  upon  the  skin  and  listen- 
ing to  the  sounds  so  produced.  Mistakes  can  be  avoided  in  the 
majority  of  cases  by  holding  the  chest  piece  of  the  stethoscope  very 
firmly  against  the  chest.  This  can  be  easily  done  when  the  patient 
is  in  the  recumbent  position,  but  when  the  patient  is  sitting  up  it 
may  be  necessary  to  press  so  hard  with  the  chest  piece  of  the  stetho- 
scope as  to  throw  the  patient  off  his  balance  unless  he  is  in  some 
way  supported;  accordingly,  it  is  my  practice  in  many  cases  to  put 
the  left  arm  around  and  behind  the  patient  so  as  to  form  a  support, 
against  which  he  can  lean  when  the  chest  piece  of  the  stethoscope 
is  pressed  strongly  against  his  chest.  When  listening  to  the  back 
of  the  chest,  the  manoeuvre  is  reversed.  If  the  skin  is  very  dry,  the 
ribs  are  very  prominent,  or  the  chest  is  thickly  covered  with  hair, 
it  may  be  impossible  to  prevent  the  occurrence  of  adventitious  sounds 
due  to  friction  of  the  chest  piece  upon  the  chest,  no  matter  how 
firmly  the  instrument  is  held.  In  case  of  doubt,  and  in  any  case  in 
which  a  diagnosis  of  fine  rales  or  of  pleural  or  pericardial  friction  is 
in  question,  the  chest  piece  of  the  stethoscope,  the  fingers  of  the 
hand  which  holds  it  and  the  surface  of  the  chest,  at  the  point  where 
we  desire  to  listen,  should  be  moistened  and  any  hair  that  may  be  pres- 
ent thoroughly  wetted  with  a  sponge,  so  that  it  will  lie  fiat  upon 
the  chest.  Otherwise  the  friction  of  the  hair  under  the  chest  piece 
of  the  stethoscope  may  simulate  crepitant  rales  as  closely  as  "skin 
rubs"  simulate  pleural  friction. 

(3)  The  friction  of  the  fingers  of  the  auscultator  upon  the  chest 
piece  or  on  some  other  part  of  the  stethoscope  frequently  gives  rise 
to  sounds  closely  resembling  rales  of  one  or  another  description. 
The  nature  of  these  sounds  can  be  easily  learned  by  intentionally 
moving  the  fingers  upon  the  stethoscope.  They  are  to  be  avoided 
by  wetting  the  fingers,  grasping  the  bell  firmly,  and  by  touching  it 
with  as  few  fingers  as  will  suffice  to  hold  it  close  against  the  chest. 

(4)  Noises  produced  by  a  shifting  of  the  parts  of  the  stetho- 
scope upon  each  other  are  especially  frequent  in  stethoscopes  made 
in  several  pieces  and  jointed  together.  A  variety  of  snapping  and 
cracking  sounds,  not  at  all  unlike  certain  varieties  of  rales,  may 
thus  be  produced,  and  if  we  are  not  upon  our  guard,  may  lead  to 


AUSCULTATION  145 

errors  in  diagnosis.  Stethoscopes  which  have  no  hinges  and  which 
do  not  come  apart  are  far  less  Hkely  to  trouble  us  in  this  way. 

(5)  When  a  rubber  band  is  used  to  press  the  ear  pieces  more 
firmly  into  the  ears,  a  very  peculiar  sound  may  be  produced  by  the 
breathing  of  the  auscultator  as  it  strikes  upon  the  rubber  strap.  It 
is  a  loud  musical  note,  and  may  be  confused  with  coarse,  dry  rales. 

When  one  has  learned  to  recognize  and  to  disregard  the  noises 
produced  in  the  ways  above  indicated,  there  is  still  one  set  of  sounds 
which  are  very  frequently  heard,  yet  which  have  no  significance  for 
physical  diagnosis,  and  must  therefore  be  disregarded;  I  refer  to 

B.  Muscle  Sounds. 

Patients  who  hold  themselves  very  erect  while  being  exam- 
ined, or  who  for  any  reason  contract  the  muscles  of  that  portion  of 
the  chest  over  which  we  are  listening,  produce  in  these  muscles  a 
very  peculiar  and  characteristic  set  of  sounds.  The  contraction  of 
any  muscle  in  the  body  produces  sounds  similar  in  quality  to  those 
heard  over  the  chest,  but  of  less  intensity. 

Those  who  have  the  faculty  of  contracting  the  tensor  tympani 
muscle  at  will  can  at  any  time  listen  to  a  typical  muscle  sound.  Or 
close  both  ears  with  the  fingers  and  strongly  contract  the  masseter 
muscle,  with  the  teeth  clenched.  A  low-pitched  muscle  sound  will 
be  heard, 

It  is  well  also  to  have  a  patient  contract  one  of  the  pectorals  and 
then  listen  to  the  sound  thus  produced.  In  some  cases  a  continuous, 
low-pitched  roar  or  drumming  is  all  that  we  hear ;  in  other  cases  we  hear 
nothing  but  the  breath  sounds  during  expiration,  while  during  inspira- 
tion the  breath  sound  is  obscured  by  a  series  of  short,  dull,  rumbling 
sounds,  following  each  other  at  the  rate  of  from  five  to  ten  in  a  second. 
Occasionally  the  sound  is  like  the  puffing  of  the  engine  attached  to 
a  pile-driver,  or  like  a  stream  of  water  falling  upon  a  sheet  of  metal 
just  slowly  enough  to  be  separated  into  drops  and  heard  at  a  con- 
siderable distance.  As  already  mentioned,  we  are  especially  apt  to 
hear  these  muscle  sounds  during  forced  inspiration,  owing  to  the 
contraction  of  voluntary  muscles  during  that  portion  of  the  respira- 
tory act.  They  are  most  often  heard  over  the  upper  portion  of  the 
chest  (over  the  pectorals  in  front  and  over  the  trapezius  behind), 
but  in  some  persons  no  part  of  the  chest  is  free  from  them.  It 
is  a  curious  fact  that  we  are  not  always  able  to  detect  by  sight  or 
touch  the  muscular  contractions  which  give  rise  to  these  sounds, 
10 


146  .     PHYSICAL  DIAGNOSIS 

and  the  patient  himself  may  be  wholly  unaware  of  them.  Under 
such  circumstances  they  are  not  infrequently  mistaken  for  rales, 
and  I  am  inclined  to  think  that  many  of  the  sounds  recorded  as 
"crumpling,"  "obscure,"  "muffled,"  "distant,"  or  " indeterminate " 
rales  are  in  reality  due  to  muscular  contractions.  The  adjectives 
"muflfied"  and  "distant"  give  us  an  inkling  as  to  the  qualities  which 
distinguish  muscular  sounds  from  rales.  Rales  are  more  clean  cut, 
have  a  more  distinct  beginning  and  end,  seem  nearer  to  the  ear,  and 
possess  more  of  a  crackling  or  bubbling  quality  than  muscle  sounds. 
I  have  made  no  attempt  exhaustively  to  describe  all  the  sounds 
due  to  muscular  contractions  and  conducted  to  the  ear  by  the  stetho- 
scope, but  have  intended  simply  to  call  attention  to  the  importance 
of  studying  them  carefully. 

C.  Other  Sources  of  Error. 

Another  source  of  confusion,  which  for  beginners  is  very  trouble- 
some, especially  if  they  are  using  the  ordinary  form  of  stethoscope 
with  a  bell-shaped  chest  piece,  arises  in  case  the  chest  piece  is  not 
held  perfectly  in  apposition  with  the  skin.  If,  for  example,  the 
stethoscope  is  slightly  tilted  to  one  side  so  that  the  bell  is  lifted 
from  the  skin  at  some  point,  or  if  one  endeavors  to  listen  over  a 
very  uneven  part  of  the  chest  on  which  the  bell  of  the  stethoscope 
cannot  be  made  to  rest  closely,  a  roar  of  external  noises  reaches  the 
ear  through  the  chink  left  between  the  chest  piece  and  the  chest. 
After  a  little  practice  one  learns  instantly  to  detect  this  condition 
of  things  and  so  to  shift  the  position  of  the  chest  piece  that  external 
noises  are  totally  excluded;  but  by  the  beginner,  the  peculiar  babel 
of  external  noises  which  is  heard  whenever  the  stethoscope  fails  to 
fit  closely  against  the  chest  is  not  easily  recognized,  and  hence  he 
tends  to  attribute  some  of  these  external  sounds  to  diseased  conditions 
within  the  chest. 

Again,  it  is  not  until  we  have  had  considerable  practice  that 
our  sense  of  hearing  comes  instantly  to  tell  us  when  something  is 
wrong  about  the  stethoscope  itself;  when,  for  example,  one  of  the 
tubes  is  blocked,  kinked,  or  disconnected,  or  when  we  are  holding 
the  stethoscope  upside  down,  so  that  the  ear  pieces  point  downward 
instead  of  upward  (see  Figs.  113  and  114).  It  is  only  when  we  have 
learned  through  long  practice  about  how  much  we  ought  to  hear 
at  a  given  point  in  the  normal  chest  that  we  recognize  at  once  the 
fact  that  we  are  not  hearing  as  much  as  we  should,  in  case  some  one 


AUSCULTATION  147 

of  the  above  accidents  has  happened.  Many  beginners  do  not  Hsten 
long  enough  in  any  one  place,  but  move  the  chest  piece  of  the  steth- 
oscope about  rapidly  from  point  to  point,  as  they  have  seen  experienced 
auscultators  do;  but  it  is  remarkable  how  much  more  one  can  hear 
at  a  given  point  by  simply  persevering  and  listening  to  beat  after 
beat,  or  breath  after  breath.  It  is  sometimes  difficult  to  avoid  the 
impression  that  the  sounds  themselves  have  grown  louder  as  we 
continue  to  listen,  especially  if  we  are  in  any  doubt  as  to  what  we  hear. 
Therefore,  if  we  hear  indistinctly,  it  is  important  to  keep  on  listening, 
and  to  fix  the  attention  successively  upon  each  of  the  different  elements 
in  the  sounds  under  consideration.     In  difficult  cases  we  should  use 


Fig.  113. — Stethoscope  Held  Fig.  114. — Stethoscope  Held 

Right  Side  Up.  Wrong  Side  Up. 

every  possible  aid  toward  concentration  of  the  attention,  and  where 
it  is  possible,  all  sources  of  distraction  should  be  eliminated.  Thus, 
in  any  case  of  doubt,  I  think  it  is  important  for  the  auscultator  to 
get  himself  into  as  comfortable  a  position  as  he  can,  so  that  his 
attention  is  not  distracted  by  his  own  physical  discomforts.  Many 
auscultators  shut  their  eyes  when  listening  in  a  difficult  case  so  as 
to  avoid  the  distraction  of  impressions  coming  through  the  sense  of 
sight.  It  goes  without  saying  that  if  quiet  can  be  secured  in  the 
room  where  we  are  working,  and  outside  it  as  well,  we  shall  be  enabled 
to  listen  much  more  profitably. 

Auscultation  of  the  Lungs. 

In  the  majority  of  cases  ordinary  quiet  breathing  is  not  forcible 
enough  to  bring  out  the  sounds  on  which  we  depend  for  the  diagnosis 
of  the  condition  of  the  lungs.  Deep  or  forced  breathing  is  what  we 
need. 

As  a  rule,  the  patient  must  be  taught  how  to  breathe  deeply,  which 


148  PHYSICAL  DIAGNOSIS 

is  best  accomplished  by  personally  demonstrating  the  act  of  deep 
breathing  and  then  asking  him  to  do  the  same.  Two  difficulties  are 
encountered : 

(a)  The  patient  may  blow  out  his  breath  forcibly  and  with  a  noise, 
since  that  is  what  he  is  used  to  doing  whenever  he  takes  a  long  breath 
under  ordinary  circumstances;  or 

(b)  It  may  be  that  he  cannot  be  made  to  take  a  deep  breath  at  all. 
The  first  of  these  mistakes  alters  the  sounds  to  be  heard  with  the 
stethoscope  in  any  part  of  the  chest  by  disturbing  both  the  rhythm 
and  the  pitch  of  the  respiratory  sounds.  In  this  way  the  breathing 
may  be  made  to  sound  tubular  or  asthmatic  throughout  a  sound  chest. 
This  difficulty  can  sometimes  be  overcome  by  demonstrating  to  the 
patient  that  what  you  desire  is  to  have  him  open  his  mouth,  take  a 
full  breath  and  then  simply  let  it  go,  but  not  blow  it  forcibly  out.  In 
some  cases  the  patient  cannot  be  taught  this,  and  we  have  to  get  on 
the  best  we  can  despite  his  mistakes.  When  he  cannot  be  made  to 
take  a  full  breath  at  all,  we  can  often  accomplish  the  desired  result  by 
getting  him  to  cough.  The  breath  just  before  and  after  a  cough  is 
often  of  the  type  we  desire.  The  use  of  voluntary  cough  in  order  to 
bring  out  rales  will  be  discussed  later  on.  Another  useful  manoeuvre 
is  to  make  the  patient  count  aloud  as  long  as  he  can  with  a  single 
breath.  The  deep  inspiration  which  he  is  forced  to  take  after  this 
task  is  of  the  type  which  we  desire. 

I.  Respiratory  Types. 

In  the  normal  chest  two  types  of  breathing  are  to  be  heard : 

(i)   Tracheal,  bronchial,  or  tubular  breathing. 

(2)   Vesicular  breathing. 

Tracheal,  bronchial,  or  tubular  breathing  is  to  be  heard  in  normal 
cases  if  the  stethoscope  is  pressed  against  the  trachea,  and  as  a  rule  it 
can  also  be  heard  over  the  situation  of  the  primary  bronchi,  in  front  or 
behind  (see  Figs.  115  and  116). 

Vesicular  breathing  is  to  be  heard  over  the  remaining  portions  of 
the  lung — -that  is,  in  the  front  of  the  thorax  except  where  the  heart 
and  the  liver  come  against  the  chest  wall,  in  the  back  except  where  the 
presence  of  the  scapulae  obscures  it,  and  throughout  both  axillae. 

(i)   Characteristics  of  Vesicular  Breathing. 

Vesicular  breathing — that  heard  over  the  air  vesicles  or  paren- 
chyma of  the  lung — has  certain  characteristics  which  I  shall  try  to 
describe  in  terms  of  intensity,  duration,  and  pitch. 


AUSCULTATION. 


149 


Of  the  quality  of  the  sounds  heard  over  this  portion  of  the  lung 
there  is  little  can  be  said;  it  sounds  something  like  the  swish  of  the 
wind  in  a  grove  of  trees  some  distance  off,  and  hence  is  sometimes 
spoken  of  as  "breezy." 

The  intensity,  duration,  and  pitch  of  the  inspiration  as  compared 
with  that  of  the  expiration  may  be  represented  as  in  Fig.  117.-  In 
this  figure,  as  in  all  those  to  be  used  in  description  of  respiratory 
sounds — 

(i)  I  represent  the  inspiration  by  an  up-stroke  and  the  expira- 
tion by  a  down-stroke  (see  the  direction  of  the  arrows  in  Fig.  117). 


Fig.  115. — Situation  of  the  Trachea  and 
Primary  Bronchi. 


Fig.   116. — Situation  of  the  Trachea  and 
Primary  Bronchi. 


(2)  The  length  of  the  up-stroke  as  compared  with  that  of  the 
down-stroke  corresponds  to  the  length  of  inspiration  compared  with 
expiration. 

(3)  The  thickness  of  the  up-stroke  as  compared  with  the  down- 
stroke  represents  the  intensity  of  the  inspiration  as  compared  with 
the  expiration. 

(4)  The  pitch  of  inspiration  as  compared  with  that  of  expiration 
is  represented  by  the  sharpness  of  the  angle  which  the  up-stroke  makes 
with  the  perpendicular  as  compared  with  that  which  the  down-stroke 
makes  with  the  perpendicular.  The  pitch  of  a  roof  may  be  thought 
of  in  this  connection  to  remind  us  of  the  meaning  of  these  symbols. 

If  now  we  look  again  at  Fig.  117  we  see  that  when  compared  with 
expiration  (the  down-stroke) ,  the  inspiration  is — 


150 


PHYSICAL  DIAGNOSIS 


(a)   More  intense. 

(&)   Longer. 

(c)   Higher  pitched. 

Our  comparison  is  invariably  made  between  inspiration  and  ex- 
piration, and  not  with  any  other  sound  as  a  standard. 

Now,  this  t^^pe  of  breathing  (which,  as  I  have  said,  is  to  be  heard 
over  every  portion  of  the  lung  except  those  portions  immediately 
adjacent  to  the  primary  bronchi),  is  not  heard  everywhere  with  equal 
intensity.  It  is  best  heard  below  the  clavicles  in  front,  in  the  axillae, 
and  below  the  scapulae  behind;  over  the  thin,  lower  edges  of  the  lung, 
whether  behind  or  at  the  sides,  it  is  feebler,  though  still  retaining  its 
characteristic  type  as  revealed  in  the  inspiration  and  expiration  in 
respect    to    intensity,    duration,    and    pitch.     To    represent    distant 


Fig.  117. — ^\^esicular 
Breathing. 


Fig.  1x8.^ — Distant 
Vesicular  Breathing. 


Fig.  119. — Exaggerated 
Vesicular  Breathing. 


vesicular  breathing  graphically  we  have  only  to  draw  its  symbol  on  a 
smaller  scale  (see  Fig.  118).  On  the  other  hand,  when  one  listens  to 
the  lungs  of  a  person  who  has  been  exerting  himself  strongly,  one  hears 
the  same  type  of  respiration,  but  on  a  larger  scale,  which  may  then  be 
represented  as  in  Fig.  119.  This  last  symbol  may  also  be  used  to 
represent  the  respiration  which  we  hear  over  normal  but  thin-walled 
chests;  for  example,  in  children  or  in  emaciated  persons.  It  is  some- 
times known  as  "exaggerated"  or  "puerile"  respiration.  When  one 
lung  is  thrown  out  of  use  by  disease  so  that  increased  work  is  brought 
upon  the  other,  the  breath  sounds  heard  over  the  latter  are  increased 
and  seem  to  be  produced  on  a  larger  scale.  Such  breathing  is  some- 
times spoken  of  as  "rough"  breathing. 

It  is  very  important  to  distinguish  at  the  outset  between  the 
different  types  of  breathing,  one  of  which  I  have  just  described,  and 
the  different  degrees  of  loudness  with  which  any  one  type  of  breathing 
may  be  heard. 

(2)   Bronchial  or  Tracheal  Breathing  in  Health. 
Bronchial  breathing  may  be  symbolically  represented  as  in  Fig.  1 20^ 
in  which  the  increased  length  of  the  down-stroke  corresponds  to  the 


AUSCULTATION  .      15 

increased  duration  of  expiration,  and  the  greater  thickness  of  both 
lines  corresponds  to  the  greater  intensity  of  both  sounds,  expiratory 
and  inspiratory,  while  the  sharp  pitch  of  the  "gable"  on  both  sides  of 
the  perpendicular  corresponds  to  the  high  pitch  of  both  sounds.  Ex- 
piration, it  will  be  noticed,  slightly  exceeds  inspiration  both  in  inten- 
sity and  pitch,  and  considerably  exceeds  it  in  duration,  while  as 
compared  with  vesicular  breathing  almost  all  the  relations  are  reversed. 
Bronchial  breathing  has  also  a  peculiar  quality  which  can  be  better 
appreciated  than  described. 

In  the  healthy  chest  this  type  of  breathing  is  to  be  heard  if  one 
listens  over  the  trachea  or  primary  bronchi  (see  above.  Fig.  115),  but 
practically  one  hardly  ever  listens  over  the  trachea  and  bronchi  except 
by  mistake,  and  the  importance  of  familiarizing  one's  self  with  the 


Fig.  120. — Bronchial  Breath-      FiG.  121. — Distant  Bronchial       Fig.  122. — ^Very  Loud 
ing  of  Moderate  Intensity.  Breathing.  Bronchial  Breathing. 


type  of  respiration  heard  over  these  portions  of  the  chest  is  due  to  the 
fact  that  in  certain  diseases,  especially  in  pneumonia  and  phthisis, 
we  may  hear  bronchial  breathing  over  the  parenchyma  of  the  lung 
where  normally  vesicular  breathing  should  be  heard. 

The  student  should  famih arize  himself  with  each  of  these  types 
of  breathing,  the  vesicular  and  the  bronchial,  concentrating  his  at- 
tention as  he  listens  first  upon  the  inspiration  and  then  upon  the 
expiration,  and  comparing  them  with  each  other,  first  in  duration, 
next  in  intensity,  and  lastly  in  pitch.  To  those  who  have  not  a 
musical  ear,  high-pitched  sounds  convey  the  general  impression  of 
being  shrill,  while  low-pitched  sounds  sound  hollow  and  empty,  but 
the  distinction  between  intensity  and  pitch  is  one  comparatively 
difficult  to  master.  Distant  bronchial  breathing  may  be  repre- 
sented in  Fig.  121,  and  is  to  be  heard  over  the  back  of  the  neck 
opposite  the  position  of  the  trachea  and  bronchi.  Fig.  122  repre- 
sents very  loud  bronchial  breathing  such  as  is  sometimes  heard  in 
pneumonia. 


152 


PHYSICAL  DIAGNOSIS 


(3)    Broncho-Vesicular  Breathing  in  Health. 

As  indicated  by  its  name,  this  type  of  breathing  is  intermediate 
between  the  two  just  described,  hence  the  terms  "mixed  breathing," 
or  "atypical  breathing"  (" unbestimmt ") .  Its  characteristics  may 
be  symbolized  as  in  Fig.  123.  In  the  normal  chest  one  can  become 
famiUar  with  broncho-vesicular  breathing,  by  examining  the  apex  of 
the  right  lung,  or  by  listening  over  the  trachea  or  one  of  the  primary 
bronchi,  and  then  moving  the  stethoscope  half  an  inch  at  a  time 
toward  one  of  the  nipples.  In  the  course  of  this  journey  one  passes 
over  points  at  which  the  breathing  has,  in  varying  degrees,  the  charac- 
teristics  intermediate   between   the  bronchial  type  from   which   we 


Fig.   123. — Two   Common  Types  of 
Broncho-Vesicular  Breathing. 


^ 


Fig.  124. — Distant  Broncho-Vesicular 
Breathing. 


started  and  the  vesicular  type  toward  which  we  are  moving.  Expira- 
tion is  a  little  longer,  intenser,  or  higher  pitched  than  in  vesicular 
breathing,  and  inspiration  a  little  shorter,  feebler,  or  lower  pitched ;  but 
since  these  characteristics  are  variously  combined,  there  are  many 
subvarieties  of  broncho-vesicular  breathing  which,  for  purposes  of 
convenience  (see  below,  page  290) ,  I  have  called  the  first  type  of  broncho- 
vesicular  breathing  (see  Figs.  123,  a,  and  124,  a)  and  the  second  type  of 
broncho-vesicular  breathing  (Figs.  123,  b,  and  124,  b)  or  B-V-I,  and 
B-V-II.  The  first  type  is  identical  with  that  often  called  "sharp " — 
because  inspiration  is  sharp  or  high  pitched.  In  this  type  the  inspira- 
tion is  often  segmented  ("cog-wheel  breathing"). 


(4)    The  Breathing  in  Emphysema. 

A  glance  at  Fig.  125  will  call  up  the  most  important  features  of  this 
type  of  respiration.  The  inspiration  is  short  and  somewhat  feeble, 
but  not  otherwise  remarkable.  The  expiration  is  long,  feeble,  and  low 
pitched.  This  type  of  breathing  is  the  rule  in  elderly  persons,  particu- 
larly those  of  the  male  sex. 


AUSCULTATION 


153 


(5)    The  Breathing  in  Asthma. 

Fig.  126  differs  from  emphysematous  only  in  the  greater  intensity 
of  the  inspiration.  In  this  type  of  breathing,  however,  both  sounds 
are  usually  obscured  to  a  great  extent  by  the  presence  of  piping  and 
squeaking  rales  (see  below) . 


Fig.  125. — Emphysematous  Breathing.         FiG.   126. — Asthmatic  Breathing,     s,  s,  s 

squeaking  (musical)  rales. 

(6)   Interrupted  or  ''Cogwheel"  Breathing. 

As  a  rule,  only  the  inspiration  is  interrupted,  being  transformed 
into  a  series  of  short,  jerky  puffs  as  shown  in  Fig.  128.  Very  rarely 
the  expiration  is  also  divided  into  segments.  Inspiration  is  also 
abnormally  high  pitched  in  most  cases.  When  heard  over  the  entire 
chest,  cogwheel  breathing  is  usually  the  result  of  nervousness,  fatigue, 
or  chilliness  on  the  patient's  part.  With  the  removal  of  these  causes 
this  type  of  respiration  then  disappears.  If,  on  the  other  hand,  cog- 
wheel respiration  is  confined  to  a  relatively  small  portion  of  the  chest, 
and  remains  present  despite  the  exclusion  of  fatigue,  nervousness,  or 


Fig.  127. — Cogwheel  Breathing. 


Fig.   1 28. — Metamorphosing  Breathing. 


cold,  it  points  to  a  local  catarrh  in  the  finer  bronchi  such  as  to  render 
difficult  the  entrance  of  air  into  the  alveoli.  As  such,  it  has  a  certain 
significance  in  the  diagnosis  of  early  phthisis,  a  significance  similar  to 
that  of  rales  or  other  signs  of  localized  bronchitis  (see  below) .  Cog- 
wheel breathing  must  be  distinguished  from  cardio-respiratory  mur- 
murs which  have  the  qualities  of  breath  sounds,  hut  occur  only  with  the 
systole  of  the  heart.  Such  murmurs  are  very  often  heard  at  the  left 
base  behind,  but  have,  so  far  as  I  know,  no  clinical  importance. 


154  PHYSICAL  DIAGNOSIS 

(7)  Amphoric  or  Cavernous  Breathing  (see  below,  p.  158). 
(8)  Metamorphosing  Breathing. 
Occasionally,  while  we  are  listening  to  an  inspiration  of  normal 
pitch,  intensity,  and  quality,  a  sudden  metamorphosis  occurs  and  the 
type  of  breathing  changes  from  vesicular  to  bronchial  or  amphoric 
(see  Fig.  128),  or  the  intensity  of  the  breath  sounds  may  suddenly 
be  increased  without  other  change.  These  metamorphoses  are  usu- 
ally owing  to  the  fact  that  a  plugged  bronchus  is  suddenly  opened 
by  the  force  of  the  inspired  air,  so  that  the  sounds  conducted  through 
it  become  audible. 

II.  Differences  between  the  Two  Sides  of  the  Chest. 

(a)  Over  the  apex  of  the  right  lung — ^that  is,  above  the  right  clav- 
icle in  front,  and  above  the  spine  of  the  scapula  behind — one  hears  in 
the  great  majority  of  normal  chests  a  distinctly  broncho-vesicular  type 
of  breathing.  In  a  smaller  number  of  cases  this'same  type  of  breathing 
may  be  heard  just  below  the  right  clavicle.  These  facts  cannot  be  too 
strongly  insisted  upon,  since  it  is  only  by  bearing  them  in  mind  that  we 
can  avoid  the  mistake  of  diagnosing  a  beginning  consolidation  of  the 
right  apex  where  none  exists.  Breath  sounds  which  are  perfectly  normal 
over  the  right  apex  would  mean  serious  disease  if  heard  over  similar  por- 
tions of  the  left  lung.  It  will  be  remembered  that  the  apex  of  the  right 
lung  is  also  duller  on  percussion  than  the  corresponding  portion  of  the 
left,  and  that  the  voice  sounds  and  tactile  fremitus  are  normally  more 
intense  on  the  right  (see  Fig.  86).  The  best  explanation  of  these  dif- 
ferences seems  to  .me  that  given  by  Petterolf  (Archives  of  Int.  Med., 
Feb.,  1909),  who  has  shown  that  the  apex  of  the  right  lung  is  in  close 
contact  with  the  trachea,  while  the  left  lung-apex  is  separated 
from  the  trachea  by  the  large  blood  vessels,  the  gullet  and  other 
structures.  The  tracheal  or  bronchial  sounds  are  therefore  better 
transmitted  to  the  right  lung. 

(6)  At  the  base  of  the  left  lung  posteriorly  one  often  hears  a  slightly 
rougher  or  more  noisy  type  of  breathing  than  in  the  corresponding 
portion  of  the  right  lung.^ 

III.  Pathological  Modifications  of  Vesicular  Breathing. 

Having  now  distinguished  the  different  types  of  breathing  and 
described  their  distribution  in  the  normal  chest,  we  must  return  to 

^  If  the  patient  lies  on  the  side,  that  side  shows  a  slightly  more  tubular  respiration 
with  increased  voice,  whisper,  and  fremitus.  This  must  be  allowed  for  in  all  comparisons 
made  in  this  position. 


AUSCULTATION  155 

the  normal  or  vesicular  breathing  in  order  to  enumerate  certain  of  its 

modifications  which  are  important  in  diagnosis. 

(i)   Exaggerated     Vesicular    Breathing    ("Compensatory"    Breathing). 

(a)  It  has  already  been  mentioned  that  in  children  or  in  adults 
with  very  thin  and  flexible  chests  the  normal  breath  sounds  are  heard 
with  relatively  great  distinctness;  also  that  after  any  exertion  which 
leads  to  abnormally  deep  and  forcible  breathing  a  similar  increase  in 
the  intensity  of  the  respiratory  sounds  naturally  occurs. 

(b)  The  term  "compensatory  breathing,"  or  "vicarious"  breathing, 
refers  to  vesicular  breathing  of  an  exaggerated  type,  such  as  is  heard, 
for  example,  over  the  whole  of  one  lung  when  the  other  lung  is  thrown 
out  of  use  by  the  pressure  of  an  accumulation  of  air  or  fluid  in  the 
pleural  cavity.  A  similar  exaggeration  of  the  breathing  upon  the 
sound  side  takes  place  when  the  other  lung  is  solidified,  as  by  tuber- 
culosis, pneumonia,  or  malignant  disease,  or  when  it  is  compressed  by 
the  adhesions  following  pleuritic  effusion,  or  by  a  contraction  of  the 
bones  of  that  side  of  the  chest  such  as  occurs  in  spinal  curvature. 

(2)   Diminished  Vesicular  Breathing. 

The  causes  of  a  diminution  in  the  intensity  of  the  breath  sounds 
without  any  change  in  their  type  are  very  numerous.  I  shall  mention 
them  in  an  order  corresponding  as  nearly  as  possible  to  the  relative 
frequency  of  their  occurrence. 

(a)  Fluid,  Air,  or  Solid  in  the  Pleural  Cavity. — ^Probably  the 
commonest  cause  for  a  diminution  or  total  abolition  of  normal  breath 
sounds  is  an  accumulation  of  fluid  in  the  pleural  cavity  such  as  occurs 
in  inflammation  of  the  pleura  or  by  transudation  (hydrothorax) .  In 
such  cases  the  layer  of  fluid  intervening  between  the  lung  and  the 
stethoscope  of  the  auscultator  causes  retraction  of  the  lung  so  that 
little  or  no  vesicular  murmur  is  produced  in  it,  and  hence  none  is 
transmitted  to  the  ear  of  the  auscultator.  An  accumulation  of  air  in 
the  pleural  cavity  (pneumothorax)  may  diminish  or  abolish  the  breath 
sounds  precisely  as  a  layer  of  fluid  does ;  in  a  somewhat  different  way  a 
thickening  of  the  costal  or  pulmonary  pleura  or  a  malignant  growth  of 
the  chest  wall  may  render  the  breath  sounds  feeble  or  prevent  their 
being  heard  because  the  vibrations  of  the  thoracic  sounding-board  are 
thus  deadened.  Whichever  of  these  causes,  fluid  or  air  or  solid,  inter- 
venes between  the  lung  and  the  ear  of  the  auscultator,  the  breath 
sounds  are  deadened  or  diminished  without,  as  a  rule,  any  modification 
of  their  type.     The  amount  of  such  diminution  depends  roughly  on 


156  PHYSICAL  DIAGNOSIS 

the  thickness  of  the  layer  of  extraneous  substance,  whether  fluid,  air, 
or  solid. 

Total  absence  of  breath  sounds  may  therefore  be  due  to  any  one 
of  these  causes,  provided  the  layer  intervening  between  the  lung  and 
chest  wall  is  of  sufficient  thickness  to  produce  complete  atelectasis  of 
the  lung  or  to  deaden  the  vibrations  of  the  chest  wall. 

(6)  Emphysema  of  the  lung,  by  destroying  its  elasticity  and  reducing 
the  extent  of  its  movements,  makes  the  breath  sounds  relatively 
feeble,  but  seldom,  if  ever,  abolishes  them  altogether. 

(c)  In  bronchitis  the  breath  sounds  are  sometimes  considerably 
diminished  owing  to  the  filling  up  of  the  bronchi  with  secretion.  This 
diminution,  however,  usually  attracts  but  little  attention,  owing  to  the 
fact  that  the  bubbling  and  squeaking  sounds,  which  result  from  the 
passage  of  air  through  the  bronchial  secretions,  distract  our  notice  to 
such  an  extent  that  we  find  it  difficult  to  concentrate  attention  upon 
the  breath  sounds,  even  if  we  do  not  forget,  altogether  to  listen  to  them. 
When,  however,  we  succeed  in  listening  through  the  rales  to  the  breath 
sounds  themselves,  we  usually  notice  that  they  are  very  feeble,  espe- 
cially over  the  lower  two-thirds  of  the  chest.  (Edema  of  the  lung  may 
diminish  the  breath  sounds  in  a  similar  way. 

{d)  Pain  in  the  thorax,  such  as  is  produced  by  dry  pleurisy  or 
intercostal  neuralgia,  diminishes  the  breath  sounds  because  it  leads 
the  patient  to  restrain,  so  far  as  possible,  the  movements  of  his  chest, 
and  so  of  his  lungs.  If,  for  any  other  reason,  the  full  expansion  of  the 
lung  does  not  take  place,  whether  on  account  of  the  feebleness  of  the 
respiratory  movements  or  because  the  lung  is  mechanically  hindered 
by  the  presence  of  pleuritic  adhesions,  the  breath  sounds  are  propor- 
tionately feeble. 

{e)  Occlusion  of  the  upper  air  passages,  as  by  spasm  or  oedema  of  the 
glottis,  renders  the  breathing  very  feeble  on  both  sides  of  the  chest. 
If  one  of  the  primary  bronchi  is  occluded,  as  by  a  foreign  body  or  by 
pressure  of  a  tumor  or  enlarged  gland  from  without,  we  may  get  a 
unilateral  enfeeblement  of  the  breathing  over  the  corresponding  lung. 

(/)  Occasionally  a  paralysis  of  the  muscles  of  respiration  on  one  or 
both  sides  is  found  to  result  in  a  unilateral  or  bilateral  enfeeblement 
of  the  breathing. 

It  should  be  remembered,  when  estimating  the  intensity  of  the 
breathing,  that  the  sounds  heard  over  the  right  base  are,  as  a  rule, 
slightly  more  feeble  than  those  heard  over  the  left  base  in  the  normal 
chest. 


AUSCULTATION  157 

IV.   Bronchial  or  Tubular  Breathing  in  Disease. 

(a)  I  have  already  described  the  occurrence  of  bronchial  breathing 
in  parts  of  the  normal  chest,  namely,  over  the  trachea  and  primary 
bronchi.  In  disease,  bronchial  breathing  may  be  heard  elsewhere  in 
the  chest,  and  usually  points  to  solidification  of  that  portion  of  lung 
from  which  it  is  conducted.  It  is  heard  most  commonly  in  phthisis 
(see  below,  p.  285). 

{b)  Croupous  pneumonia  is  probably  the  next  most  frequent  cause 
of  bronchial  breathing,  although  by  no  means  every  case  of  croupous 
pneumonia  shows  this  sign.  For  a  more  detailed  account  of  the 
conditions  under  which  it  does  or  does  not  occur  in  croupous  pneumo- 
nia, see  below,  p.  277.  Lobular  pneumonia  is  rarely  manifested  by 
tubular  breathing. 

(c)  In  about  one-third  of  the  cases  of  pleuritic  effusion  distant 
bronchial  breathing  is  to  be  heard  over  the  fluid.  On  account  of  the 
feebleness  of  the  breath  sounds  in  such  cases  they  are  often  put  down 
as  absent,  as  we  are  so  accustomed  to  associate  intensity  with  the 
bronchial  type  of  breathing.  One  should  be  always  on  the  watch  for 
any  degree  of  intensity  of  bronchial  breathing  from  the  feeblest  to  the 
most  distinct.  In  empyema — especially  in  children — the  bronchial 
breathing  heard  over  the  fluid  may  be  intense  and  often  leads  to  a 
false  diagnosis  of  unresolved  pneumonia  or  phthisis. 

When  the  breath  sounds  are  enfeebled  at  the  base  of  the  thorax  by 
an  accumulation  of  fluid  there  is  often  a  layer  of  bronchial  or  broncho- 
vesicular  breathing  a  little  higher  up  near  the  root  of  the  lung  which  is 
compressed  by  the  fluid  outside  or  below  it.  (See  also  changes  associ- 
ated with  pericardial  effusion,  p.  258.) 

{d)  Rarer  causes  of  bronchial  breathing  are  hemorrhagic  infarction 
of  the  lung,  syphilis,  or  malignant  disease,  any  one  of  which  may  cause 
a  solidification  of  a  portion  of  the  lung. 

V.   Broncho- Vesicular  Breathing  in  Disease. 

Respiration  of  this  type  should  be  carefully  distinguished  from 
puerile  or  exaggerated  breathing,  in  which  we  hear  the  normal  vesicu- 
lar respiration  upon  a  large  scale.  I  have  already  mentioned  that 
broncho-vesicular  breathing  is  normally  to  be  heard  over  the  apex  of 
the  right  lung.  In  disease,  broncho-vesicular  breathing  is  heard  in 
other  portions  of  the  lung,  and  usually  denotes  a  moderate  degree  of 
solidification  of  the  lung,  such  as  occurs  in  early  phthisis  or  in  the 
earliest  and  latest  stages  of  croupous  pneumonia.     In  cases  of  pleuritic 


158  PHYSICAL  DIAGNOSIS 

effusion,  one  can  usually  hear  broncho-vesicular  breathing  over  the 
upper  portion  of  the  affected  side,  owing  to  the  retraction  of  the  lung 
at  that  point. 

VI.  Amphoric  Breathing  {Amphora  =  A  Jar). 

Respirations  have  a  hollow,  empty  sound  like  that  produced  by 
blowing  across  the  top  of  a  bottle,  are  occasionally  heard  in  disease 
over  pulmonary  cavities  (e.g.,  in  phthisis)  or  in  pneumothorax,  i.e., 
under  conditions  in  which  the  air  passes  in  and  out  of  a  large  empty 
cavity  within  the  chest.  Amphoric  breathing  never  occurs  in  health. 
The  pitch  of  both  sounds  is  low,  but  that  of  expiration  lower  than  that  of 
inspiration.  The  intensity  and  duration  of  the  sounds  vary,  and  the 
distinguishing  mark  is  their  quality  which  resembles  that  of  a  whispered 
"who." 

VII.    R^LES. 

The  term  "rales"  is  applied  to  sounds  produced  by  the  passage  of 
air  through  bronchi  which  contain  mucus  or  pus,  or  which  are  narrowed 
by  swelling  of  their  walls. ^     Rales  are  best  classified  as  follows: 

(i)  Bubbling  rales,  including  (a)  coarse,  (b)  medium,  and  (c)  fine 
rales. 

(2)  Crackling  rales  (large,  medium,  or  fine). 

The  smallest  varieties  of  this  type  are  known  as  "crepitant"  or 
"  subcrepitant "  rales. 

(3)  Musical  rales  (high  or  low  pitched) . 

Each  of  these  varieties  will  now  be  described  more  in  detail. 

(i)   Bubbling  Rales. 

The  nature  of  these  is  sufficiently  indicated  by  their  name.  The 
coarsest  or  largest  bubbles  are  those  produced  in  the  trachea,  and 
ordinarily  known  as  the  "death  rattle."  Tracheal  rales  occur  in  any 
condition  involving  either  profound  unconsciousness  or  very  great 
weakness,  so  that  the  secretions  which  accumulate  in  the  trachea  are 
not  coughed  out.  Tracheal  rales  are  by  no  means  a  sure  precursor  of 
death,  although  they  are  very  common  in  the  moribund  state.  They 
can  usually  be  heard  at  some  distance  from  the  patient  and  without  a 

^  Rales  are  of  all  auscultatory  phenomena  the  easiest  to  appreciate,  provided  we 
exclude  various  accidental  sounds  which  may  be  transmitted  to  the  ear  as  a  result  of 
friction  of  the  stethoscope  against  the  skin  or  against  the  fingers  of  the  observer.  (See 
above,  page  144.) 


AUSCULTATION  159 

Stethoscope.  In  catarrh  of  the  larger  bronchi  large  bubbling  rales  are 
occasionally  to  be  heard.  In  phthisical  cavities  one  sometimes  hears 
coarse,  bubbling  rales  of  a  very  metallic  and  gurgling  quality  (see 
below,  p.  290).  The  finer  grades  of  rales  correspond  to  the  finer 
bronchi. 

In  the  majority  of  cases  these  rales  are  most  numerous  during 
inspiration  and  especially  during  the  latter  part  of  this  act.  Their 
relation  to  respiration  may  be  represented  graphically  as  in  Fig.  129, 
using  large  dots  for  coarse  rales  and  small  dots  for  fine  rales.  Musical 
rales  can  be  symbolized  by  the  letter  5  (squeaks). 

(2)    Crackling  Rales. 

These  differ  from  the  preceding  variety  merely  by  the  absence  of 
any  distinct  bubbling  quality.  They  are  usually  to  be  heard  in  cases 
of  bronchitis  in  which  the  secretions  are  unusually  tenacious  and  viscid. 
They  are  especially  apt  to  come  at  the  end  of  inspiration,  a  large 
number  being  evolved  in  a  very  short  space  of  time,  so  that  one  often 
speaks  of  an  "explosion  of  fine  crackling  rales"  at  the 
end  of  inspiration.  Crackling  rales  are  to  be  heard  in 
any  one  of  the  conditions  in  which  bubbling  rales  occur, 
but  are  more  frequent  in  tuberculosis  than  in  simple 
bronchitis.  There  is  some  doubt  whether  or  not  fine 
crackles  can  be  produced  in  a  pleural  exudate,  old  or 

new,  but  personally  I  am  convinced  that  they  are  not 
.    r  f  ,1  Fig.  129. — 

mfrequently  so  produced.  Explosion    of 

Crepitant  rales,  which  represent  the  finest  sounds  of  pi^e  Rales  at 
this  type,  are  very  much  like  the  noise  which  is  heard  End  of  Inspi- 
when  one  takes  a  lock  of  hair  between  the  thumb  and  ration, 
first  finger  and  rubs  the  hairs  upon  each  other  while 
holding  them  close  to  the  ear.  A  very  large  number  of  minute 
crackling  sounds  is  heard  following  each  other  in  rapid  succession. 
To  the  inexperienced  ear  they  may  seem  to  blend  into  a  continuous 
sound,  but  with  practice  the  component  parts  may  be  distinguished. 
This  type  of  rales  is  especially  apt  to  occur  during  inspiration  alone, 
but  not  very  infrequently  they  are  heard  during  expiration  as  well. 
From  subcrepitant  rales  they  are  distinguished  merely  by  their  being 
still  finer  than  the  latter.^     Subcrepitant  rales  are  often  mixed  with 

^A  distinction  was  formerly  drawn  between  crepitant  and  subcrepitant  rales,  on  the 
ground  that  the  latter  were  heard  both  during  both  respiratory  sounds  and  the  former 
only  dtiring  inspiration,  but  this  distinction  cannot  be  maintained  and  is  gradually  being 
given  up. 


160  PHYSICAL  DIAGNOSIS 

sounds  of  a  somewhat  coarser  type,  while  crepitant  rales  are  usually 
all  of  a  size.  If  the  chest  is  covered  with  hair,  sounds  precisely  like 
these  two  varieties  of  rales  may  be  heard  when  the  stethoscope  is 
placed  upon  the  hairy  portions.  To  avoid  mistaking  these  sounds  for 
rales  one  must  thoroughly  wet  or  grease  the  hair. 

Crepitant  Rales  in  Atelectasis. 

Crepitant  and  subcrepitant  rales  are  very  often  to  be  heard  along 
the  thin  margins  of  the  lungs  at  the  base  of  the  axillae  and  in  the  back, 
especially  when  a  patient  who  is  breathing  superficially  first  begins 
to  take  deep  breaths.  In  such  cases,  they  usually  disappear  after 
the  few  first  respirations,  and  are  then  to  be  explained  by  the  tearing 
apart  of  the  slightly  agglutinated  surfaces  of  the  finer  bronchioles. 

It  is  by  no  means  invariably  the  case,  however,  that  such  subcrep- 
itant rales  are  merely  transitory  in  their  occurrence.  In  a  large  number 
of  cases  they  persist  despite  deep  breathiiig.  The  frequency  of 
subcrepitant  rales,  persistent  or  transitory,  heard  over  the  inferior 
margin  of  the  normal  lung  at  the  bottom  of  the  axilla,  is  shown  by 
the  following  figures:  Out  of  356  normal  chests  to  which  I  have 
listened  especially  for  these  rales,  I  found  228,  or  61  per  cent. ,  which 
showed  them  on  one  or  both  sides.  They  are  very  rarely  to  be  heard 
in  persons  under  twenty  years  of  age.  After  forty-five,  on  the  other 
hand,  it  is  unusual  not  to  find  them.  In  my  experience  they  are 
considerably  more  frequent  in  the  situation  shown  in  Fig.  182  than  in 
any  other  part  of  the  lung,  but  they  may  be  occasionally  heard  in  the 
back  or  elsewhere.  In  view  of  these  facts,  it  seems  to  me  that  we 
must  recognize  that  it  is  almost  if  not  quite  physiological  to  find  the 
finer  varieties  of  crackling  rales  at  the  base  of  the  axillae  in  persons  over 
forty  years  old.  I  have  supposed  these  rales  to  be  due  to  a  partial 
atelectasis  resulting  from  disuse  of  the  thin  lower  margin  of  the  lungs. 
Such  portions  of  the  lung  are  ordinarily  not  expanded  unless  the 
respirations  are  forced  and  deep.^  This  explanation  would  agree 
with  the  observations  of  Abrams,  to  which  I  shall  refer  later  (see  below, 

P-  335)- 

(6)  Crepitant  or  subcrepitant  rales  are  also  to  be  heard  in  a  certain 
portion  of  cases  of  pneumonia,  in  the  very  earliest  stages  and  when 
resolution  is  taking  place  ("  crepitans  redux  ") .  More  rarely  this  type 
of  rale  may  be  heard  in  connection  with  tuberculosis,  infarction,  or 
oedema  of  the  lung. 

^  So  as  to  expand  the  lung  and  produce  the  "  entf altungsgerausch "  of  the  Germans. 


AUSCULTATION  161 

In  certain  cases  of  dry  pleurisy  there  occur  fine  crackling  sounds 
which  can  scarcely  be  differentiated  from  subcrepitant  rales.  I  shall 
return  to  the  description  of  them  in  speaking  of  pleural  friction  (see 
below,  p.  314). 

(3)   Mtisical  Rales. 

The  passage  of  air  through  bronchial  tubes  narrowed  by  inflam- 
matory swelling  of  their  lining  membrane  (bronchitis),  by  dropsical 
effusions  or  by  spasmodic  contraction  (asthma),  gives  rise  not  infre- 
quently to  a  multitude  of  musical  sounds.  Such  a  stenosis  occurring 
in  relatively  large  bronchial  tubes  produces  a  deep-toned  groaning 
sound,  while  narrowing  of  the  finer  tubes  results  in  piping,  squeaking, 
whistling  noises  of  various  qualities.  Such  sounds  are  often  known 
as  "dry  rales"  in  contradistinction  to  the  "bubbling  rales"  above 
described,  but  as  many  non-musical  crackling  rales  have  also  a  very 
dry  sound,  it  seems  to  me  best  to  apply  the  more  distinctive  term 
"  musical  rales  "  to  all  adventitious  sounds  of  distinctly  musical  quality, 
giving  up  the  term  "dry"  altogether.  Musical  rales  are  of  all  adven- 
titious sounds  the  easiest  to  recognize  but  also  the  most  fugitive  and 
changeable.  They  appear  now  here,  now  there,  shifting  from  minute 
to  minute,  and  may  totally  disappear  from  the  chest  and  reappear 
again  within  a  very  short  time.  This  is  to  some  extent  true  of  all 
varieties  of  rales,  but  especially  of  the  squeaking  and  groaning 
varieties. 

Musical  rales  are  heard,  as  a  rule,  more  distinctly  during  expiration, 
especially  when  they  occur  in  connection  with  asthma  or  emphysema. 
In  these  diseases  one  may  hear  quite  complicated  chords  from  the 
combinations  of  rales  which  vary  in  pitch. 

VIII.  The  Effects  of  Cough. 

The  influence  of  coughing  upon  rales  may  be  either  to  intensify 
them  and  bring  them  out  where  they  have  not  previously  been  heard, 
or  to  clear  them  away  altogether.  Lateral  decubitus  multiplies  and 
intensifies  rales  on  the  lower  side.  Other  effects  of  coughing  upon 
physical  signs  will  be  mentioned  later  (pp.  278,  285). 

IX.  Pleural  Friction. 

The  surfaces  of  the  healthy  pleural  cavity  are  lubricated  with 
sufficient  serum  to  make  them  pass  noiselessly  over  each  other  during 
11 


162  PHYSICAL  DIAGNOSIS 

the  movements  of  respiration.  But  when  the  tissues  become  abnorm- 
ally dry,  as  in  Asiatic  cholera,  or  when  the  serous  surfaces  are 
roughened  by  the  presence  of  a  fibrinous  exudation,  as  in  ordinary 
pleurisy,  the  rubbing  of  the  two  pleural  surfaces  against  one  another 
produces  peculiar  and  very  characteristic  sounds  known  as  "pleural 
friction  sounds.'''  The  favorite  seat  of  pleural  friction  sounds  is  at  the 
bottom  of  the  axilla,  i.e.,  where  the  lung  makes  the  widest  excursion 
and  where  the  costal  and  diaphragmatic  pleura  are  in  close  apposition 
(see  Fig.  87).  In  some  cases  pleural  friction  sounds  are  to  be  heard 
altogether  below  the  level  of  the  lung.  In  others  they  may  extend  up 
several  inches  above  its  lower  margin,  and  occasionally  it  happens 
that  friction  may  be  appreciated  over  the  whole  lung  from  the  top  to 
the  bottom.  Very  rarely  friction  sounds  are  heard  only  at  the  apex 
of  the  lung  in  early  tuberculosis. 

The  sound  of  pleural  friction  may  be  closely  imitated  by  holding 
the  thumb  and  forefinger  close  to  the  ear,  and  rubbing  them  past  each 
other  with  strong  pressure,  or  by  pressing  the  palm  of  one  hand  over 
the  ear  and  rubbing  upon  the  back  of  this  hand  with  the  fingers  of  the 
other.  Pleural  friction  is  usually  a  catchy,  jerky,  interrupted,  ir- 
regular sound,  and  is  apt  to  occur  during  inspiration  only,  and  particu- 
larly at  the  end  of  this  act.  It  may,  however,  be  heard  with  both 
respiratory  acts,  but  rarely  if  ever  occurs  during  expiration  alone. 
The  intensity  and  quality  of  the  sounds  vary  a  great  deal,  so  that  they 
may  be  compared  to  grazing,  rubbing,  rasping,  and  creaking  sounds. 
They  are  sometimes  spoken  of  as  "leathery."  As  a  rule,  they  seem 
very  near  to  the  ear,  and  are  sometimes  startlingly  loud.  In  many 
cases  they  cannot  be  heard  after  the  patient  has  taken  a  few  full 
breaths,  probably  because  the  rough  pleural  surfaces  are  smoothed 
down  temporarily  by  the  friction  which  deep  breathing  produces. 
After  a  short  rest,  however,  and  a  period  of  superficial  breathing, 
pleural  friction  sounds  often  return  and  can  be  heard  for  a  short  time 
with  all  their  former  intensity.  They  are  increased  by  pressure 
exerted  upon  the  outside  of  the  chest  wall.  Such  pressure  had  best  be 
made  with  the  hand  or  with  the  Bowles  stethoscope,  since  the  sharp 
edges  of  the  chest-piece  of  the  ordinary  stethoscope  may  give  rise  to 
considerable  pain;  but  if  such  pressure  is  made  with  the  hand,  one 
must  be  careful  not  to  let  the  hand  shift  its  position  upon  the  skin, 
else  rubbing  sounds  may  thus  be  produced  which  perfectly  simulate 
pleural  friction.  In  well-marked  cases  pleuritic  friction  can  be  felt 
if  the  palm  of  the  hand  is  laid  over  the  suspected  area;  occasionally  the 
sound  is  so  loud  that  it  can  be  heard  by  the  patient  himself  or  by  those 


AUSCULTATION  163 

around  him.  F.  T.  Lord^  has  recently  called  attention  to  a  sound  a 
good  deal  like  pleural  friction,  often  heard  over  the  scapulae  when 
examining  patients  whose  arms  are  folded  across  the  chest  with  each 
hand  on  the  opposite  shoulder.  The  sound  apparently  starts  in  the 
shoulder  joint  on  one  side  or  both  sides — usually  both.  It  is  less  jerky 
and  irregular  than  pleural  friction,  can  often  be  abolished  by  shifting 
the  position  of  the  arms,  and  causes  no  pain. 

X.  Auscultation  of  the  Spoken  or  Whispered  Voice  Sounds. 
The  more  important  of  these  is: 

(a)    The  Whispered  Voice. 

The  patient  is  directed  to  whisper  "one,  two,  three,"  or  "ninety- 
nine,"  while  the  auscultator  listens  over  different  portions  of  the  chest 
to  see  to  what  degree  the  whispered  syllables  are  transmitted.  In 
the  great  majority  of  normal  chests  the  whispered  voice  is  to  be  heard 
only  over  the  trachea  and  primary  bronchi  in  front  and  behind,  while 
over  the  remaining  portions  of  the  lung  little  or  no  sound  is  to  be 
heard.  When,  on  the  other  hand,  solidification  of  the  lung  is  present, 
the  whispered  voice  may  be  distinctly  heard  over  portions  of  the  lung 
relatively  distant  from  the  trachea  and  bronchi;  for  example,  over  the 
lower  lobes  of  the  lung  behind.  The  usefulness  of  the  whispered  voice 
in  the  search  for  small  areas  of  solidification  or  for  the  exact  boundaries 
of  a  solidified  area  is  very  great,  especially  when  we  desire  to  save  the 
patient  the  pain  and  fatigue  of  taking  deep  breaths.  Whispered  voice 
sounds  are  practically  equivalent  to  a  forced  expiration  and  can  be 
obtained  with  very  little  exertion  on  the  patient's  part.  The  in- 
creased transmission  of  the  whispered  voice  is,  in  my  opinion,  a  more 
delicate  test  for  solidification  than  tubular  breathing.  The  latter 
sign  is  present  only  when  a  considerable  area  of  lung  tissue  is  solidified, 
while  the  increase  of  the  whispered  voice  may  be  obtained  over  much 
smaller  areas.  Retraction  of  the  lung  above  the  level  of  a  pleural 
effusion  causes  a  moderate  increase  in  the  transmission  of  the  whispered 
voice,  and  at  times  this  increased  or  bronchial  whisper  is  to  be  heard 
over  the  fluid  itself,  probably  by  transmission  from  the  compressed 
lung  above. 

Where  the  lung  is  completely  solidified  the  whispered  words  may 
be  clearly  distinguished  over  the  affected  area.  In  lesser  degrees  of 
solidification  the  syllables  are  more  or  less  blurred. 

^  F.  T.  Lord:  Boston  Med.  &  Surg.  Journal,  Oct.  21,  1909. 


164  PHYSICAL  DIAGNOSIS 

(b)    The  Spoken  Voice. 

The  evidence  given  us  by  listening  for  the  spoken  voice  in  various 
parts  of  the  chest  is  considerably  less  in  value  than  that  obtained 
through  the  whispered  voice.  As  a  rule,  it  corresponds  with  the 
tactile  fremitus,  being  increased  in  intensity  by  the  same  causes  which 
increase  tactile  fremitus,  viz.,  solidification  or  condensation  of  the  lung, 
and  decreased  by  the  same  causes  which  decrease  tactile  fremitus — 
namely,  by  the  presence  of  air  or  water  in  the  pleural  cavity,  by  the 
thickening  of  the  pleura  itself,  or  by  an  obstruction  of  the  bronchus 
leading  to  the  part  over  which  we  are  listening.  In  some  cases  the 
presence  of  solidification  of  the  lung  gives  rise  not  merely  to  an  increase 
in  transmission  of  the  spoken  voice,  but  to  a  change  in  its  quality,  so 
that  it  sounds  abnormally  concentrated,  nasal,  and  near  to  the  listen- 
er's ear.  The  latter  change  may  be  heard  over  areas  where  tactile 
fremitus  is  not  increased,  and  even  where  it  is  diminished.  Where 
this  change  in  the  quality  of  the  voice  occurs,  the  actual  words 
spoken  can  often  be  distinguished  in  a  way  not  usually  possible  over 
either  normal  or  solidified  lung.  "Bronchophony,"  or  the  distinct 
transmission  of  audible  words,  and  not  merely  of  diffuse,  unrecogniz- 
able voice  sounds,  is  considerably  commoner  in  the  solidifications 
due  to  pneumonia  than  in  those  due  to  phthisis;  it  occurs  in  some 
cases  of  pneumothorax  and  pulmonary  cavity. 


(c)   Egophony. 

Among  the  least  important  of  the  classical  physical  signs  is  a 
nasal  or  squeaky  quality  of  the  sounds  which  reach  the  observer's 
ear  when  the  patient  speaks  in  a  natural  voice.  To  this  peculiar 
quality  of  voice  the  name  of  "egophony"  has  been  given.  It  is  most 
frequently  heard  in  cases  of  moderate-sized  pleuritic  effusion  just 
about  the  level  of  the  lower  angle  of  the  scapula  and  in  the  vicinity  of 
that  point.  Less  often  it  is  heard  at  the  same  level  in  front.  It  is 
very  rarely  heard  in  the  upper  portion  of  the  chest  and  is  by  no  means 
constant  either  in  pleuritic  effusion  or  in  any  other  condition.  A  point 
at  which  it  is  heard  corresponds  not,  as  arule,  with  the  upper  level  of 
the  accumulated  fluid,  as  has  been  frequently  supposed,  but  often  with 
a  point  about  an  inch  farther  down.  The  presence  of  egophony  is  in 
no  way  distinctive  of  pleuritic  effusions  and  may  be  heard  occasionally 
over  solidified  lung^. 


AUSCULTATION  165 

XL  Phenomena  Peculiar  to  Pneumohydrothorax  and  Pneumo- 

PYOTHORAX. 

(i)   Succussion  Sounds. 

Now  and  then  a  patient  consults  a  physician,  complaining  that  he 
hears  noises  inside  him  as  if  water  were  being  shaken  about.  One 
such  patient  expressed  himself  to  me  to  the  effect  that  he  felt  "like  a 
half-empty  bottle."  In  the  chest  of  such  a  patient,  if  one  presses  the 
ear  against  any  portion  of  the  thorax  and  then  shakes  the  whole  patient 
strongly  (succussion),  one  may  hear  loud  splashing  sounds  due  to  air 
and  fluid  within.  The  sound  itself  is  often  miscalled  "succussion." 
Such  sounds  are  absolutely  diagnostic  of  the  presence  of  both  air  and 
fluid.  Very  frequently  they  may  be  detected  by  the  physician  when 
the  patient  is  not  aware  of  their  presence.  Occasionally  the  splashing 
of  the  fluid  within  may  be  felt  as  well  as  heard.  It  is  essential,  of 
course,  to  distinguish  splashing  due  to  the  presence  of  air  and  fluid  in 
the  pleural  cavity  from  similar  sounds  produced  in  the  stomach,  but 
this  is  not  at  all  diflficult  in  the  majority  of  cases.  It  is  a  bare  possibility 
that  succussion  sounds  may  be  due  to  the  presence  of  air  and  fluid  in 
the  pericardial  cavity,  or  in  the  stomach  or  gut  escaped  into  the 
thorax  through  a  ruptured  diaphragm.  In  accident  cases  this 
possibility  must  be  remembered. 

It  is  important  to  remember  that  splashing  is  never  to  be  heard 
in  simple  pleuritic  effusion  or  hydrothorax.  The  presence  of  air,  as 
well  as  liquid,  in  the  pleural  cavity  is  absolutely  essential  to  the  pro- 
duction of  succussion  sounds.^ 

(2)   Metallic  Tinkle  or  Falling-Drop  Sound. 

When  listening  over  a  pleural  cavity  which  contains  both  air  and 
fluid,  one  occasionally  hears  a  liquid,  tinkling  sound,  due  possibly 
to  the  impact  of  a  drop  of  liquid  falling  from  the  relaxed  lung  above 
into  the  accumulated  fluid  at  the  bottom  of  the  pleural  cavity,  but 

^  It  is  well  for  the  student  to  try  for  himself  the  following  experiment,  which  I  have 
found  useful  in  impressing  these  facts  upon  the  attention  of  classes  in  physical  diagnosis: 
Fill  an  ordinary  rubber  hot-water  bag  to  the  brim  with  water.  Invert  it  and  squeeze 
out  forcibly  a  certain  amount  (perhaps  half)  of  the  contents,  by  grasping  the  upper  end 
of  the  bag  and  compressing  it.  While  the  water  is  thus  being  forced  out,  screw  in  the 
nozzle  of  the  bag.  Now  shake  the  whole  bag,  and  it  will  be  found  impossible  to  produce 
any  splashing  sounds  owing  to  the  fact  that  there  is  no  air  in  the  bag.  Unscrew  the  nozzle, 
admit  air,  and  then  screw  it  in  again.  Now  shake  the  bag  again  and  loud  splashing  will 
be  easily  heard. 


166  PHYSICAL  DIAGNOSIS 

probably  to  rales  produced  in  the  tissues  around  the  cavity.  It 
is  stated  that  this  physical  sign  may  in  rare  cases  be  observed  in 
large  sized  phthisical  cavities  as  well  as  in  pneumohydrothorax  and 
pneumopyothorax. 

(3)    The  Lung-Fistula  Sound. 

When  a  perforation  of  the  lung  occurs  below  the  level  of  the  fluid 
accumulated  in  the  pleural  cavity,  bubbles  of  air  may  be  forced  out 
from  the  lung  and  up  through  the  fluid  with  a  sound  reminding  one  of 
that  made  by  children  when  blowing  soap-bubbles. 


CHAPTER  IX. 
AUSCULTATION  OF  THE  HEART. 

I.  "  Valve  Areas." 

In  the  routine  examination  of  the  heart,  most  observers  listen  in 
four  places : 

(i)  At  the  apex  of  the  heart  in  the  fifth  intercostal  space  near  the 
nipple,  the  ''mitral  area." 

(2)  In  the  second  left  intercostal  space  near  the  sternum,  the 
''pulmonic  area.'' 

(3)  In  the  second  right  intercostal  space  near  the  sternum,  the 
"  aortic  area." 


Aortic  area. 


Tricuspid  area. 


Pulmonic  area. 


Mitral  area. 


Fig.  130. — The  Valve  Areas. 

(4)  At  the  bottom  of  the  sternum  near  the  ensiform  cartilage, 
the  "tricuspid  area." 

These  points  are  represented  in  Fig.  130  and  are  known  as  "valve 
areas."  They  do  not  correspond  to  the  anatomical  position  of  any 
one  of  the  four  valves,  but  experience  has  shown  that  sounds  heard  best 
at  the  apex  can  be  proved  (by  post-mortem  examination  or  otherwise) 
to  be  produced  at  the  mitral  orifice.  They  are  probably  transmitted 
through  the  papillary  muscle  whose  base  or  insertion  is  near  the  apex 

167 


168  PHYSICAL  DIAGNOSIS 

region.  Similarly  sounds  heard  best  in  the  second  left  intercostal 
space  are  proved  to  be  produced  at  the  pulmonary  orifice ;  those  which 
are  loudest  at  the  second  right  intercostal  space  to  be  produced  at  the 
aortic  orifice;^  while  those  which  are  most  distinct  near  the  origin  of 
the  ensiform  cartilage  are  produced  at  the  tricuspid  orifice. 

II.  The  Normal  Heart  Sounds. 

A  glance  at  Fig.  131,  which  represents  the  anatomical  positions  of 
the  four  valves  above  referred  to,  illustrates  what  I  said  above; 
namely,  that  the  traditional  valve  areas  do  not  correspond  at  all  with 
the  anatomical  position  of  the  valves.  If  now  we  listen  in  the  "  mitral 
area,''  that  is,  in  the  region  of  the  apex  impulse  of  the  heart,  keeping 
at  the  same  time  one  finger  on  some  point  at  which  the  cardiac  impulse 
is  palpable,  one  hears  with  each  outward  thrust  of  the  heart  a  low, 
dull  sound,  and  in  the  period  between  the  heart  beats  a  second  sound, 
shorter  and  sharper  in  quality.^ 

That  which  occurs  with  the  cardiac  impulse  is  known  as  the  first 
sound;  that  which  occurs  between  each  two  beats  of  the  heart  is  known 
as  the  second  sound.  The  second  sound  is  generally  admitted  to  be 
due  to  the  closure  of  the  semilunar  valves.  The  cause  of  the  first 
sound  has  been  a  most  fruitful  source  of  discussion,  and  no  one  expla- 
nation of  it  can  be  said  to  be  generally  received.  Perhaps  the  most 
commonly  accepted  view  attributes  the  first  or  systolic  sound  of  the 
heart  to  a  combination  of  two  elements — - 

(a)   The  contraction  of  the  heart  muscle  itself. 

(&)   The  sudden  tautening  of  the  mitral  curtains. 

Following  the  second  sound  there  is  a  pause  corresponding  to 
the  diastole  of  the  heart.  Normally  this  pause  occupies  a  little  more 
time  than  the  first  and  second  sounds  of  the  heart  taken  together.  In 
disease  it  may  be  much  shortened. 

The  first  sound  of  the  heart  is  not  only  longer  and  duller  than  the 
second  (it  is  often  spoken  of  as  "booming"  in  contrast  with  the 
"snapping"  quality  of  the  second  sound),  but  is  also  considerably 
more  intense,  so  that  it  gives  us  the  impression  of  being  accented  like 
the  first  syllable  of  a  trochaic  rhythm.  After  a  little  practice  one 
grows  so  accustomed  to  this  rhythm  that  one  is  apt  to  rely  upon  his 

■  ^  For  the  exceptions  to  this  rule,  see  below,  page  2 14. 

^  The  first  sound  of  the  heart,  as  heard  at  the  apex,  may  be  imitated  by  holding  a  linen 
handkerchief  by  the  corners  and  suddenly  tautening  one  of  the  borders.  To  imitate  the 
second  sound,  use  one-half  the  length  of  the  border  instead  of  the  whole.  ■; 


AUSCULTATION  OF  THE  HEART  169 

appreciation  of  the  rhythm  alone  for  the  identification  of  the  systolic 
sound.  This  is,  however,  an  unsafe  practice  and  leads  to  many  errors. 
Our  impression  as  to  which  of  the  two  sounds  of  each  cardiac  cycle 
corresponds  to  systole  should  always  be  verified  either  by  sight  or 
touch.  We  must  either  see  or  feel  the  cardiac  impulse  and  assure 
ourselves  that  it  is  synchronous  with  the  heart  sound  which  we  take 
to  be  systolic.^  This  point  is  of  especial  importance  in  the  recognition 
and  identification  of  cardiac  murmurs,  as  will  be  seen  presently. 

So  far,  I  have  been  describing  the  normal  heart  sounds  heard  in 
the  "mitral  area,"  that  is,  at  the  apex  of  the  heart.     If  now  we  listen 


Tricuspid  valve.  -' 


Fig.  131. — Anatomical  Position  of  the  Cardiac  Valves. 

over  the  pulmonary  area  (in  the  second  left  intercostal  space) ,  we  find 
that  the  rhythm  of  the  heart  sounds  has  changed  and  that  here  the 
stress  seems  to  fall  upon  the  "second  sound,"  i.e.,  that  corresponding 
to  the  beginning  of  diastole;  in  other  words,  the  first  sound  of  the  heart 
is  here  heard  more  feebly  and  the  second  sound  more  distinctly.  The 
sharp,  snapping  quality  of  the  latter  is  here  even  more  marked  than 
at  the  apex,  and  despite  the  feebleness  of  the  first  sound  in  this  area 
we  can  usually  recognize  its  relatively  dull  and  prolonged    quality. 

Over  the  aortic  area  {i.e.,  in  the  second  right  interspace)  the 
rhythm  is  the  same  as  in  the  pulmonary  area,  although  the  second 
sound  may  be  either  stronger  or  weaker  than  the  corresponding  sound 
on  the  other  side  of  the  sternum  (see  below,  p.  172). 

1  When  the  cardiac  impulse  can  be  neither  seen  nor  felt,  the  pulsation  of  the  carotid 
will  generally  guide  us.     The  radial  pulse  is  not  a  safe  guide. 


170  PHYSICAL  DIAGNOSIS 

Over  the  tricuspid  area  one  hears  sounds  practically  indistinguish- 
able in  quality  and  in  rhythm  from  those  heard  at  the  apex.^ 

When  the  chest  walls  are  thick  and  the  cardiac  sounds  feeble,  it 
may  be  difficult  to  hear  them  at  all.  In  such  cases  the  heart  sounds 
may  be  heard  much  more  distinctly  if  the  patient  leans  forward  and 
toward  his  own  left.  Such  a  position  of  the  body  also  renders  it 
easier  to  map  out  the  outlines  of  the  cardiac  dulness  by  percussion  if 
we  allow  for  the  swing  of  the  heart  to  the  left. 

In  cardiac  neuroses  and  during  conditions  of  excitement  or  emo- 
tional strain,  the  first  sound  at  the  apex  is  not  only  very  loud  but  has 
often  a  curious  metallic  reverberation  {"  cliquetis  inetallique")  corre- 
sponding to  the  trembling,  jarring  cardiac  impulse  (often  mistaken 
for  a  thrill)  which  palpation  reveals. 

III.    Modifications    in    the    Intensity    of    the    Heart    Sounds. 

It  has  already  been  mentioned  that  in  young  persons  with  thin, 
elastic  chests,  the  heart  sounds  are  heard  with  greater  intensity  than  in 
older  persons  whose  chest  walls  are  thicker  and  stiffer.  In  obese, 
indolent  adults  it  is  sometimes  difficult  to  hear  any  heart  sounds  at  all, 
while  in  young  persons  of  excitable  temperament  the  sounds  may  have 
a  very  intense  and  ringing  quality.  Under  diseased  conditions  either 
of  the  heart  sounds  may  be  increased  or  diminished  in  intensity.  I 
shall  consider 

(i)   The  First  Sound  at  the  Apex  {sometimes  Called  the  Mitral  First 

Sound) . 

(a)  Increase  in  the  intensity  of  the  first  sound  at  the  apex  of  the 
heart  occurs  in  any  condition  which  causes  the  heart  to  act  with 
unusual  degree  of  force,  such  as  bodily  or  mental  exertion,  or  excite- 
ment. In  the  earlier  stages  of  infectious  fevers  a  similar  increase  in  the 
intensity  of  this  sound  may  sometimes  be  noted.  Hypertrophy  of  the 
left  ventricle  sometimes  has  a  similar  effect  upon  the  sound,  but  less 

^  A  third  heart  sound  (or  redupUcation  of  the  second  sound)  is  audible  on  careful 
auscultation  in  a  considerable  proportion  of  healthy  young  individuals — especially  if  they  lie 
on  the  left  side.  Barie  described  it  in  1893  {Semaine  med.,  1893,  xiii,  474),  and  Thayer 
{Boston  Med.  &  Surg.  Journ.,  May  7,  1908)  has  recently  recalled  it  to  notice,  believing 
it  due  to  "  the  sudden  tension  of  the  mitral  and  perhaps  at  times  tricuspid  valves  occurring 
at  the  end  of  the  first  and  most  rapid  phase  of  diastole."  This  is  probably  identical  with 
the  double  second  sound  of  mitral  stenosis  and  with  one  of  the  types  of  gallop  rhythm. 
No  diagnostic  significance  is  as  yet  clearly  associated  with  it. 


AUSCULTATION  OF  THE  HEART  171 

often  than  one  would  suppose,  while  dilatation  of  the  left  ventricle, 
contrary  to  what  one  would  suppose,  is  not  infrequently  associated 
with  a  loud,  forcible  first  sound  at  the  apex.  In  mitral  stenosis  the 
first  sound  is  usually  very  intense,  and  is  often  spoken  of  as  a  "thump- 
ing first  sound"  or  as  a  "sharp  slap." 

(b)  Shortening  and  weakening  of  the  first  sound  at  the  apex. 

In  the  course  of  continued  fevers  and  especially  in  typhoid  fever 
the  granular  degeneration  which  takes  place  in  the  heart  muscle  is 
manifested  by  a  shortening  and  weakening  of  the  first  sound  at  the 
apex,  so  that  the  two  heart  sounds  come  to  seem  much  more  alike 
than  usual.  In  the  later  stages  of  typhoid,  the  first  sound  may  become 
almost  inaudible.  The  sharp  "valvular"  quality,  which  one  notices 
in  the  first  apex  sound  under  these  conditions,  has  been  attributed  to 
the  fact  that  weakening  of  the  myocardium  has  caused  a  suppression 
of  one  of  the  two  elements  which  go  to  make  up  the  first  sound,  namely, 
the  muscular  element,  so  that  we  hear  only  the  short,  sharp  sound  due 
to  the  tautening  of  the  mitral  curtains.  Chronic  myocarditis,  or  any 
other  change  in  the  heart  wall  which  tends  to  enfeeble  it,  produces  a 
weakening  and  shortening  of  the  first  sound  similar  to  that  just  de- 
scribed. Simple  weakness  in  the  mitral  first  sound  without  any  change 
in  its  duration  or  pitch  may  be  due  to  fatty  overgrowth  of  the  heart,  to 
emphysema  or  pericardial  effusion  in  case  the  heart  is  covered  by  the 
distended  lung  or  by  the  accumulated  fluid.  Among  valvular  diseases 
of  the  heart  the  one  most  likely  to  be  associated  with  a  diminution  in 
intensity  of  the  first  apex  sound  is  mitral  regurgitation. 

(c)  Doubling  of  the  first  sound  at  the  apex. 

It  is  not  uncommon  in  healthy  hearts  to  hear  in  the  region  of  the 
apex  impulse  a  doubling  of  the  first  sound  so  that  it  may  be  suggested 
by  pronouncing  the  syllables  "turrupp"  or  "trupp."  In  health  this 
is  especially  apt  to  occur  at  the  end  of  expiration.  In  disease  it  is 
associated  with  many  different  conditions  involving  an  increase  in  the 
work  of  one  or  the  other  side  of  the  heart.  It  seems,  however,  to  be 
unusually  frequent  in  the  weakened  heart  of  nephritis  and  arterio- 
sclerosis. 

(2)   Modifications  in  the  Second  Sounds  as  Heard  at  the  Base  of  the 

Heart. 

Physiological  Variations. — ^The  relative  intensity  of  the  pulmonic 
second  sound,  when  compared  with  the  second  sound  heard  in  the 
conventional  aortic  area,  varies  a  great  deal  at  different  periods  of  life. 


172 


PHYSICAL  DIAGNOSIS 


Attention  was  first  called  to  this  by  Vierordt/  and  it  has  of  late  years 
been  recognized  by  the  best  authorities  on  diseases  of  the  heart. 

The  work  of  Dr.  Sarah  R.  Creighton,  done  in  my  clinic  during  the 
summer  of  1899,  showed  that  in  90  per  cent,  of  healthy  children  under 
ten  years  of  age,  the  pulmonic  second  sound  is  louder  than  the  aortic. 
In  the  next  decade  (from  the  tenth  to  the  twentieth  year)  the  pulmonic 
second  sound  is  louder  in  two-thirds  of  the  cases.     About  half  of  207 


100%- 

90%  — 
80%-- 
T0%- 

0-9 

10-19 

20-29 

DECADES. 
30-39   40-49 

50-59 

60-69 

70-79 

-—100% 
--90% 
—  80% 
—^ofo 

—-m% 

-—50% 
-—40% 
-—30^ 
-—30% 

—\oi„ 

\ 

\ 

\ 

\ 

m 

0 

m 

\ 

-{ 
> 

m 

\ 

I 

<in°/ 

\ 

20%- 
10%-- 

\ 

V 

^ 

^^ 

Fig.  132. — Showing  the  Per  Cent,  of  Accentuated  Pulmonic  Second  Sound  in  Each  Decade. 

Based  on  1,000  cases. 


cases,  between  the  ages  of  twenty  and  twenty-nine,  showed  an  accen- 
tuation of  the  pulmonic  second,  while  after  the  thirtieth  year  the 
number  of  cases  showing  such  accentuation  became  smaller  with  each 
decade,  until  after  the  sixtieth  year  we  found  an  accentuation  of  the 
aortic  second  in  sixty-six  out  of  sixty-eight  cases  examined.  These  facts 
are  exhibited  in  tabular  form  in  Figs.  132  and  133,  and  appear  to  show 

^Vierordt:  "Die  Messung  der  Intensitat  der  Herztone"  (Tiibingen,  1885).  See  also 
Hochsinger,  "  Die  Auscultation  des  kindlichen  Herzens";  Gibson,  "Diseases  of  the  Heart" 
(1898);  Rosenbach,  "Diseases  of  the  Heart"  (1900);  Allbutt,  "System  of  Medicine." 


AUSCULTATION  OF  THE  HEART 


173 


that  the  relative  intensity  of  the  two  sounds  in  the  aortic  and  pulmonic 
arteries  depends  primarily  upon  the  age  of  the  individual,  the  pulmonic 
sound  predominating  in  youth  and  the  aortic  in  old  age,  while  in  the 
period  of  middle  life  there  is  relatively  little  discrepancy  between  the 
two.  It  is,  therefore,  far  from  true  to  suppose  that  we  can  obtain  evi- 
dence of  a  pathological  increase  in  the  intensity  of  either  of  the  second 
sounds  at  the  base  of  the  heart  simply  by  comparing  it  with  the  other. 
Pathological  accentuation  of  the  pulmonic  second  sound  must  mean  a 


100"/ 


DECADES. 
0-9    I  10-19  i  20-29  !  30-39  ;  40-49  i  50-59  i  60-69  \  70-7t 


Fig.  133. — Showing  the  Per  Cent,  of  Accentuated  Aortic  Second  Sound  in  Each  Decade. 

Based  on  1,000  cases. 


greater  loudness  of  this  sound  than  should  be  expected  at  the  age  of  the 
patient  in  qiiestion,  and  not  simply  a  greater  intensity  than  that  of  the 
aortic  second  sound.  The  same  observation  obviously  applies  to 
accentuation  of  the  aortic  second  sound. 

Both  the  aortic  and  the  pulmonic  second  sounds  are  sometimes 
very  intense  during  emotional  excitement,  in  Graves'  disease,  after 
muscular  exertion,  and  sometimes  without  any  obvious  cause. 


174  PHYSICAL  DIAGNOSIS 

Pathological  Variations. 

A.  Accentuation  of  the  Pulmonic  Second  Sound. 

Pathological  accentuation  of  the  second  sound  occurs  especially  in 
conditions  involving  a  backing  up  of  blood  in  the  lungs,  such  as  occurs 
in  stenosis  or  insufficiency  of  the  mitral  valve,  or  in  obstructive  disease 
of  the  lungs  (emphysema,  bronchitis,  phthisis,  chronic  interstitial 
pneumonia).  Indirectly  accentuation  of  the  pulmonic  second  sound 
points  to  hypertrophy  of  the  right  ventricle,  since  without  such  hyper- 
trophy the  work  of  driving  the  blood  through  the  obstructed  lung  could 
not  long  be  performed.  If  the  right  ventricle  becomes  weakened,  the 
accentuation  of  the  pulmonic  second  sound  is  no  longer  heard. 

B.   Weakening  or  Absence  of  the  Pulmonic  Second  Sound. 

Weakening  of  the  pulmonic  second  sound  is  a  very  serious  symp- 
tom, sometimes  to  be  observed  in  cases  of  pneumonia  or  cardiac  dis- 
ease near  death.     It  is  thus  a  very  important  indication  for  prognosis. 

Pulmonary  stenosis  also  weakens  or  abolishes  the  second  sound, 
and  in  many  other  types  of  congenital  heart  disease  the  pulmonic,  as 
well  as  the  aortic^  second  sound  is  inaudible.  I  have  found  it  absent 
in  aortic  stenosis.  Indeed,  I  think  it  may  be  stated  that  with  any 
very  loud  systolic  murmur  at  the  base  of  the  heart,  we  may  find  the 
pulmonic  second  sound  gone;  why  I  do  not  know. 

C.  Accentuation  of  the  Aortic  Second  Sound. 

I  have  already  shown  that  the  aortic  second  sound  is  louder  than 
the  corresponding  sound  in  the  pulmonary  area  in  almost  every 
individual  over  sixty  years  of  age  and  in  most  of  those  over  forty.  A 
still  greater  intensity  of  the  aortic  second  sound  occurs — 

(a)  In  nephritis,  arterio-sclerosis,  or  any  condition  which  increases 
arterial  tension  and  so  throws  an  increased  amount  of  work  upon  the 
left  ventricle.  Directly,  therefore,  a  pathologically  loud  aortic  sound 
points  to  increased  resistance  in  the  peripheral  arteries  and  indirectly 
to  hypertrophy  of  the  left  ventricle. 

{h)  A  similar  increase  in  the  intensity  of  the  aortic  second  sound 
occurs  in  aneurism  or  diffuse  dilatation  of  the  aortic  arch. 

D.  Diminution   in   the   Intensity   of  the   Aortic   Second  Sound. 

Whenever  the  amount  of  blood  thrown  into  the  aorta  by  the 
contraction  of  the  left  ventricle  is  diminished,  as  is  the  case  especially 


AUSCULTATION  OF  THE  HEART  175 

in  mitral  stenosis  and  to  a  lesser  degree  in  mitral  regurgitation,  the 
aortic  second  sound  is  weakened  so  that  at  the  apex  it  may  be  inaudible. 
A  similar  effect  is  produced  by  any  disease  which  weakens  the  walls  of 
the  left  ventricle,  such  as  fibrous  myocarditis,  fatty  degeneration,  and 
cloudy  swelling.  Relaxation  of  the  peripheral  arteries  has  the  same 
effect.  In  conditions  of  collapse  the  aortic  second  sound  may  be 
almost  or  quite  inaudible. 

In  persons  past  middle  life  the  second  sounds  are  often  louder  in 
the  third  or  fourth  interspace  than  in  the  second,  so  that  if  we  listen 
only  in  the  second  space  we  may  gain  the  false  impression  that  the 
second  sounds  are  feeble. 

Accentuation  of  both  the  second  sounds  at  the  base  of  the  heart 
may  occur  in  health  from  nervous  causes  or  when  the  lungs  are  re- 
tracted by  disease  so  as  to  uncover  the  conus  arteriosus  and  the  aortic 
arch.  Under  these  conditions  the  second  sound  may  be  seen  and  felt 
as  well  as  heard.  In  a  similar  way,  an  apparent  increase  in  the  inten- 
sity of  either  one  of  the  second  sounds  at  the  base  of  the  heart  may 
be  produced  by  a  retraction  of  one  or  the  other  lung. 

Summary. — (i)  The  m^itral  first  sound  is  increased  by  hypertrophy 
and  dilatation  of  the  left  ventricle,  and  among  valvular  diseases  espe- 
cially by  mitral  stenosis.  It  is  weakened  or  reduplicated  by  parietal 
disease  of  the  heart.  Any  of  these  changes  may  occur  temporarily 
from  physiological  causes. 

(2)  The  pulmonic  second  sound  is  usually  more  intense  than  the 
aortic  in  children  and  up  to  early  adult  life.  Later  the  aortic  second 
sound  predominates.  Pathological  accentuation  of  the  second 
pulmonic  sound  usually  points  to  obstruction  in  the  pulmonary  circu- 
lation (mitral  disease,  emphysema,  etc.).  Weakening  of  the  pulmonic 
second  means  failure  of  the  right  ventricle  and  is  serious. 

(3)  The  aortic  second  sound  is  increased  pathologically  by  any 
cause  which  increases  the  work  of  the  left  ventricle  (arterio-sclerosis, 
chronic  nephritis).  It  is  diminished  when  the  blood  stream,  thrown 
into  the  aorta  by  the  left  ventricle,  is  abnormally  small  (mitral  disease, 
cardiac  failure) . 

(4)  Changes  in  the  tricuspid  sounds  are  rarely  recognizable,  while 
changes  in  the  first  aortic  and  pulmonic  sounds  have  little  practical 
significance. 

(3)   Modifications  in  the  Rhythm  of  the  Cardiac  Sounds. 

(i)  Whenever  the  walls  of  the  heart  are  greatly  weakened  by 
disease — for  example,  in  the  later  weeks  of  a  case  of  typhoid  fever — the 


176  PHYSICAL  DIAGNOSIS 

diastolic  pause  of  the  heart  is  shortened  so  that  the  cardiac  sounds 
follow  each  other  almost  as  regularly  as  the  ticking  of  a  clock;  hence 
the  term  ''tick-tack  heart."  As  this  rhythm  is  not  unlike  that  heard 
in  the  foetal  heart,  the  name  of  "embryocardia"  is  sometimes  applied  to 
it.  The  "tick-tack"  rhythm  may  be  heard  in  any  form  of  cardiac 
disease  after  compensation  has  failed,  or  in  any  condition  leading  to 
collapse. 

(2)  A  less  common  change  of  rhythm  is  that  produced  by  a  short- 
ening of  the  interval  between  the  two  heart  sounds  owing  to  an  incom- 
pleteness of  the  contraction  of  the  ventricle.  This  change  may  occur 
in  any  disease  of  the  heart  when  compensation  fails. 

(a)  The  commoner  type  is  the  presystolic  gallop  rhythm  in  which  an 
extra  sound  occurs  just  before  the  ordinary  first  sound  of  the  heart 
(practically  a  double  first  sound  with  accent  on  the  second  half). 
Such  a  rhythm  may  occur  temporarily  in  any  heart  which  is  excited 
or  overworked  from  any  cause,  but  when  permanent  it  is  usually  a 
sign  of  grave  cardiac  weakness  (nephritic  cases,  arterio-sclerosis, 
chronic  valvular   disease,    goitre,   etc.). 

(6)  Protodiastolic  Gallop  Rhythm  (doubling  of  the  second  sounds  at 
the  base  of  the  heart) .  The  extra  sound  is  probably  identical  with 
the  so-called  "third  heart  sound"  referred  to  on  page  170,  and  most 
constantly  heard  in  the  early  stages  of  mitral  stenosis. 

At  the  end  of  a  long  inspiration  this  change  may  be  observed  in 
almost  any  healthy  person  if  one  listens  at  the  base  of  the  heart.  It 
is  still  better  brought  out  after  muscular  exertion  or  by  holding  the 
breath. 

In  mitral  stenosis  the  double  diastolic  sound  is  also  to  be  heard  at 
the  apex,  and  in  the  diagnosis  of  this  disease  this  "double  shock 
sound"  during  diastole  may  be  an  important  piece  of  evidence,  and 
may  sometimes  be  felt  and  seen  as  well  as  heard.  Just  what  its 
mechanism  is,  is  disputed.  Except  in  mitral  stenosis,  it  has  no 
especial  clinical  significance. 

(4)   Metallic  Heart  Sounds. 

The  presence  of  air  in  the  immediate  vicinity  of  the  heart,  as,  for 
example,  in  pneumothorax  or  in  gaseous  distention  of  the  stomach  or 
intestine,  may  impart  to  the  heart  sounds  a  curious  metallic  quality 
such  as  is  not  heard  under  any  other  conditions. 
(5)  "Muffling,"  "Prolongation,"  or  "  Unclearness"  of  the  Heart  Sounds. 

These  terms  are  not  infrequently  met  with  in  literature,  but  their 
use  should,  I  think,  be  discontinued.     The  facts  to  which  they  refer 


AUSCULTATION  OF  THE  HEART  177 

should  be  explained  either  as  faintness  of  the  heart  sounds,  due  to  the 
causes  above  assigned,  or  as  faint,  short  murmurs.  In  their  present 
usage  such  terms  as  "muffled"  or  "unclear"  heart  sounds  represent 
chiefly  an  unclearness  in  the  mind  of  the  observer  as  to  just  what  it  is 
that  he  hears,  and  not  any  one  recognized  pathological  condition  in 
the  heart. 

IV.  Sounds  Audible  Over  the  Peripheral  Vessels. 

(i)  The  normal  heart  sounds  are  in  adults  audible  over  the  carotids 
and  over  the  subclavian  arteries.  In  childhood  and  youth  only  the 
second  heart  sound  is  thus  audible. 

(2)  In  about  7  per  cent,  of  normal  persons  a  systolic  sound  can  be 
heard  over  the  femoral  artery.  This  sound  is  obviously  not  trans- 
mitted from  the  heart,  and  is  usually  explained  as  a  result  of  the 
sudden  systolic  tautening  of  the  arterial  wall. 

In  aortic  regurgitation  this  arterial  sound  is  almost  always  audible 
not  only  in  the  femoral  but  in  the  brachial  and  even  in  the  radial,  and 
its  intensity  over  the  femoral  becomes  so  great  that  the  term  "pistol- 
shot"  sound  has  been  applied  to  it.  In  fevers,  exophthalmic  goitre, 
lead  poisoning,  and  other  diseases,  a  similar  arterial  sound  is  to  be 
heard  much  more  frequently  than  in  health. 


12 


CHAPTER  X. 
AUSCULTATION  OF  THE  HEART:  CONTINUED. 

Cardiac  Murmurs. 

(a)   Terminology. 

The  word  "murmur"  is  one  of  the  most  unfortunate  of  all  the  terms 
used  in  the  description  of  physical  signs.  No  one  of  the  various 
blowing,  whistling,  rolling,  rumbling,  or  piping  noises  to  which  the 
term  refers,  sounds  anything  like  a  "murmur"  in  the  ordinary  sense 
of  the  word.  Nevertheless,  it  does  not  seem  best  to  try  to  replace  it 
by  any  other  term.  The  French  word  "souffle"  is  much  more  accurate 
and  has  become  to  some  extent  Anglicized.  Under  the  head  of  cardiac 
murmurs  are  included  all  abnormal  sounds  produced  within  the  heart 
itself.  Pericardial  friction  sounds  and  those  produced  in  that  portion 
of  the  lung  or  pleura  which  overlies  the  heart  are  not  considered 
"murmurs." 

(b)   Mode  of  Production. 

With  rare  exceptions  all  cardiac  murmurs  are  produced  at  or  near 
one  of  the  valve  orifices,  either  by  disease  of  the  valves  themselves 
resulting  in  shrivelling,  thickening,  stiffening,  and  narrowing  of  the 
valve  curtains,  or  by  a  stretching  of  the  orifice  into  which  the  valves 
are  inserted. 

Diseases  of  the  valves  themselves  may  lead  to  the  production  of 
murmurs : 

(a)  When  the  valves  fail  to  close  at  the  proper  time  (incompetence, 
insufficiency,  or  regurgitation) . 

(b)  When  the  valves  fail  to  open  at  the  proper  time  (stenosis  or 
obstruction) . 

(c)  When  the  surfaces  of  the  valves  or  of  the  parts  immediately 
adjacent  are  roughened  so  as  to  prevent  the  smooth  flow  of  the  blood 
over  them. 

(d)  When  the  orifice  which  the  valves  are  meant  to  close  is  dilated 
as  a  result  of  dilatation  of  the  heart  chamber  of  which  it  forms  the 

178 


AUSCULTATION  OF  THE  HEART  179 

entrance  or  exit.  The  valves  themselves  cannot  enlarge  to  keep  pace 
with  the  enlargement  of  the  orifice,  and  hence  no  longer  suffice  to 
reach  across  it. 

The  presence  of  any  one  of  these  lesions  gives  rise  to  eddies  in  the 


Fig.  134. — Diagram  to  Illustrate  the  Production  of  a  Cardiac  Murmur  Through 
Regurgitation  from  the  Aorta  or  in  an  Aneurismal  Sac.  The  arrow  shows  the  direction 
of  the  blood  current  and  the  curled  lines  the  audible  blood  eddies. 

blood  current  and  thereby  to  the  abnormal  sounds  to  which  we  give 
the  name  murmurs.^  (See  Figs.  134,  135  and  136.)  When  valves 
fail  to  close  and  so  allow  the  blood  to  pass  back  through  them,  we 
speak  of  the  lesion  as  regurgitation,  insufficiency,  or  incompetence ;  if, 


■<- 


Fig.  135. — Diagram  to  Illustrate  the  Production  of  a  Cardiac  Murmur  Through  Stenosis 

of  a  Valve-Orifice. 

for  example,  the  aortic  valves  fail  to  close  after  the  left  ventricle  has 
thrown  a  column  of  blood  into  the  aorta,  some  of  this  blood  regurgi- 
tates through  these  valves  into  the  ventricle  from  which  it  has  just 
been  expelled,  and  we  speak  of  the  lesion  as  "aortic  regurgitation," 


Fig.  136. — Diagram  to  Illustrate  the  Production  of  Cardiac  Murmurs  Through  Roughening 

of  a  Valve. 

and  of  the  murmur  so  produced  as  an  aortic  regurgitant  murmur  or  a 
murmur  of  aortic  regurgitation.  A  similar  regurgitation  from  the 
left  ventricle  into  the  left  auricle  takes  place  in  case  the  mitral  valve 

^  The  method  by  which  functional  murmurs  are  produced  will  be  discussed  later. 
(See  page  186.) 


180  PHYSICAL  DIAGNOSIS 

fails  to  close  at  the  beginning  of  systole.  If,  on  the  other  hand,  the 
mitral  valve  fails  to  open  properly  to  admit  the  blood  which  should 
flow  during  diastole  from  the  left  auricle  into  the  left  ventricle,  we 
speak  of  the  condition  as  mitral  stenosis  or  mitral  obstruction.  A 
similar  narrowing  of  the  aortic  valves  such  as  to  hinder  the  egress  of 
blood  during  the  systole  of  the  left  ventricle  is  known  as  aortic  stenosis 
or  obstruction.  Valvular  lesions  of  the  right  side  of  the  heart  (tri- 
cuspid and  pulmonic  valves)  are  comparatively  rare,  but  are  produced 
and  named  in  a  way  similar  to  those  just  described. 

The  facts  most  important  to  know  about  a  murmur  are : 

(i)  Its  place  in  the  cardiac  cycle. 

(2)  Its  point  of  maximum  intensity. 

(3)  The  area  over  which  it  can  be  heard. 

(4)  The  effects  of  exertion,  respiration,  or  position  upon  it. 
Less  important  than  the  above  are : 

(5)  Its  intensity. 

(6)  Its  quality. 

(7)  Its  length. 

(8)  Its  relation  to  the  normal  sounds  of  the  heart. 

Each  of  these  points  will  now  be  taken  up  in  detail : 
(i)  Time  of  Murmurs. — The  first  and  most  important  thing  to 
ascertain  regarding  a  murmur  is  its  relation  to  the  normal  cardiac 
cycle;  that  is,  whether  it  occurs  during  systole  or  during  diastole,  or  in 
case  it  does  not  fill  the  whole  of  one  of  those  periods,  in  what  part  of 
systole  or  diastole  it  occurs.  It  must  be  borne  in  mind  that  the  period 
of  systole  is  considered  as  lasting  from  the  beginning  of  the  first  sound 
of  the  heart  up  to  the  occurrence  of  the  second  sound,  while  diastole 
lasts  from  the  beginning  of  the  second  sound  until  the  beginning  of  the 
first  sound  in  the  next  cycle.  Any  murmur  occurring  with  the  first 
sound  of  the  heart,  or  at  the  time  when  the  first  sound  should  take 
place,  or  in  any  part  of  the  period  intervening  between  the  first  sound 
and  the  second,  is  held  to  be  systolic.  Murmurs  which  distinctly  follow 
the  first  sound  or  do  not  begin  until  the  first  sound  is  ended  are  known 
as  late  systolic  murmurs. 

On  the  other  hand,  it  seems  best,  for  reasons  to  be  discussed  more 
in  detail  later  on,  not  to  give  the  name  of  diastolic  to  all  murmurs  which 
occur  within  the  diastolic  period  as  above  defined.  Murmurs  which 
occur  during  the  last  part  of  diastole  and  which  run  up  to  the  first 
sound  of  the  next  cycle  are  usually  known  as  "presystolic"  murmurs. 
All  other  murmurs  occurring  during  diastole  are  known  as  diastolic. 


AUSCULTATION  OF  THE  HEART  181 

The  commonest  of  all  the  errors  in  the  diagnosis  of  disease  of  the 
heart  is  to  mistake  systole  for  diastole,  and  thereby  to  misinterpret  the 
significance  of  a  murmur  heard  during  those  periods.  This  mistake 
would  never  happen  if  we  were  always  careful  to  make  sure,  by  means 
of  sight  or  touch,  just  when  the  systole  of  the  heart  occurs.  This  may 
be  done  by  keeping  one  finger  upon  the  apex  impulse  of  the  heart  or 
upon  the  carotid  artery  while  listening  for  murmurs,  or,  in  case  the 
apex  impulse  or  the  pulsations  of  the  carotid  are  better  seen  than  felt, 
we  can  control  by  the  eye  the  impressions  gained  by  listening.  It  is 
never  safe  to  trust  our  appreciation  of  the  cardiac  rhythm  to  tell  us 
which  is  the  first  heart  sound  and  which  the  second.  The  proof  of  this 
statement  is  given  by  the  numberless  mistakes  made  through  disre- 
garding it.  Equally  untrustworthy  as  a  guide  to  the  time  of  systole 
and  diastole  is  the  radial  pulse,  which  follows  the  cardiac  systole  at  an 
interval  just  long  enough  to  mar  our  calculations. 

(2)  Localizations  of  Murmurs. — To  localize  a  murmur  is  to  find  its 
point  of  maximum  intensity,  and  this  is  of  the  greatest  importance  in 
diagnosis.  Long  experience  has  shown  that  murmurs  heard  loudest  in 
the  region  of  the  apex  beat  (whether  this  is  in  the  normal  situation  or 
displaced),  are  in  the  vast  majority  of  cases  produced  at  the  mitral 
valve.  In  about  five  per  cent,  of  the  cases  mitral  murmurs  may  be 
best  heard  at  a  point  midway  between  the  position  of  the  normal  car- 
diac impulse  and  the  ensiform  cartilage,  or  (rarely)  an  inch  or  two 
above  this  situation. 

Murmurs  heard  most  loudly  in  the  second  left  intercostal  space  are 
almost  invariably  produced  at  the  pulmonic  orifice  or  just  above  it  in 
the  conus  arteriosus. 

Murmurs  whose  maximum  intensity  is  at  the  root  of  the  ensiform 
cartilage  or  within  a  radius  of  an  inch  and  a  half  from  this  point  are 
usually  produced  at  the  tricuspid  orifice.  Murmurs  produced  at  the 
aortic  orifice  may  be  heard  best  in  the  aortic  area,  but  in  a  large  propor- 
tion of  cases  are  loudest  on  the  other  side  of  the  sternum  at  or  about 
the  situation  of  the  fourth  left  costal  cartilage.  Occasionally  they  are 
best  heard  at  the  apex  of  the  heart  in  the  axilla  or  over  the  lower  part 
of  the  sternum  (see  below.  Fig.  159). 

(3)  Transmission  of  Murmurs. — If  a  murmur  is  audible  over  several 
valve  areas,  the  questions  naturally  arise:  "How  are  we  to  know 
whether  we  are  dealing  with  a  single  valve  lesion  or  with  several?  Is 
this  one  murmur  or  two  or  three  murmurs?"  Obviously  the  question 
can  be  asked  only  in  case  the  murmur  which  we  find  audible  in  various 
places  occupies  everywhere  the  same  time  in  the  cardiac  cycle.     It 


182  PHYSICAL  DIAGNOSIS 

must,  for  example,  be  everywhere  systolic  or  everywhere  diastolic.  A 
systolic  murmur  at  the  apex  cannot  be  supposed  to  point  to  the  same 
lesion  as  a  diastolic  murmur,  no  matter  where  the  latter  is  heard. 
But  if  we  hear  a  systolic  murmur  in  various  parts  of  the  chest,  say 
over  the  aortic,  mitral,  and  tricuspid  regions,  how  are  we  to  know 
whether  the  sound  is  simple  or  compound,  whether  produced  at  one 
valve  orifice  or  at  several? 

This  question  is  sometimes  difficult  to  answer,  and  in  a  given  case 
skilled  observers  may  differ  in  their  verdict,  but,  as  a  rule,  the  difficulty 
may  be  overcome  as  follows : 

(i)  Experience  and  post-mortem  examination  have  shown  that 
the  murmur  produced  by  each  of  the  valvular  lesions  has  its  own 
characteristic  area  of  propagation,  over  which  it  is  heard  with  an  in- 
tensity which  regularly  diminishes  as  we  recede  from  a  maximum 
whose  seat  corresponds  with  some  one  of  the  valve  areas  just  de- 
scribed. These  areas  of  propagation  are  shown  in  Figs.  147,  148,  151, 
and  156.  Any  murmur  whose  distribution  does  not  extend  beyond 
one  of  these  areas,  and  which  steadily  and  progressively  diminishes 
in  intensity  as  we  move  away  from  the  valve  area  over  which  it  is 
loudest,  may  be  assumed  to  be  due  to  a  single  valve  lesion  and  no 
more.  Provided  but  one  valve  is  diseased,  this  course  of  procedure 
gives  satisfactory  results. 

(2)  When  several  valves  are  diseased  and  several  murmurs  may 
be  expected,  it  is  best  to  start  at  some  one  valve  area,  say  in  the  mitral 
or  apex  region,  and  move  the  stethoscope  one-half  an  inch  at  a  time 
toward  one  of  the  other  valve  areas,  noting  the  intensity  of  any  mur- 
mur we  may  hear  at  each  of  the  different  points  passed  over.  As  we 
move  toward  the  tricuspid  area,  we  may  get  an  impression  best 
expressed  by  Fig.  137.  That  is,  a  systolic  murmur  heard  loudly  at  the 
apex  may  fade  away  as  we  move  toward  the  ensiform,  until  at  the  point 
X  (Fig.  137)  it  is  almost  inaudible.  But  as  we  go  on  in  the  same  direc- 
tion the  murmur  may  begin  to  grow  louder  (and  perhaps  to  change  in 
pitch  and  quality  as  well)  until  a  maximum  is  reached  at  the  tricuspid 
area,  beyond  which  the  murmur  again  fades  out. 

These  facts  justify  us  in  suspecting  that  we  are  dealing  with  two 
murmurs,  one  produced  at  the  tricuspid  and  one  at  the  mitral  orifice. 
The  suspicion  is  more  likely  to  be  correct  if  there  has  been  a  change  in 
the  pitch  and  quality  of  the  murmur  as  we  neared  the  tricuspid  orifice, 
and  may  be  confirmed  by  the  discovery  of  other  evidences  of  a  double 
lesion.  No  diagnosis  is  satisfactory  which  rests  on  the  evidence  of  mur- 
murs alone.    Changes  in  the  size  of  the  heart's  chambers  or  in  the  pulmo- 


AUSCULTATION  OF  THE  HEART 


183 


nary  or  peripheral  circulations  are  the  most  important  facts  in  the  case. 
Nevertheless  the  effort  to  ascertain  and  graphically  to  represent  the 
intensity  of  cardiac  murmurs  as  one  hstens  along  the  line  connecting 
the  valve  areas  has  its  value.  An  "hour-glass"  murmur,  such  as  that 
represented  in  Fig.  137,  generally  means  two-valve  lesions.  A  similar 
"hour-glass"  may  be  found  to  represent  the  auditory  facts  as  we  move 
from  the  mitral  to  the  pulmonic  or  to  the  aortic  areas  (see  Fig.  138) 
and,  as  in  the  previous  case,  arouses  our  suspicion  that  more  than  one 
valve  is  diseased. 

It  must  not  be  forgotten,  however,  that  "a  murmur  may  travel 
some  distance  underground  and  emerge  with  a  change  of  quality" 


Fig.  137. — Mitral  and  Tricuspid  Regurgitation.  The  intensity  of  the  systolic  murmur 
is  least  at  the  "  waist"  of  the  shaded  area  and  increases  as  one  approaches  either  end  of  it. 

Fig.  138. — Mitral  Regurgitation  and  Aortic  Stenosis.  The  systolic  murmur  is 
loudest  at  the  extremities  of  the  shaded  area  and  faintest  at  its  "waist." 


(Allbutt).  This  is  especially  true  of  aortic  murmurs,  which  are 
often  heard  well  at  the  apex  and  at  the  aortic  area,  and  faintly  in  the  in- 
tervening space,  probably  owing  to  the  interposition  of  the  right 
ventricle. 

In  such  cases  we  must  fall  back  upon  the  condition  of  the  heart 
itself,  as  shown  by  inspection,  palpation,  and  percussion,  and  upon  the 
condition  of  the  pulmonary  and  peripheral  circulation,  as  shown  in 
the  other  symptoms  and  signs  of  the  cases    (dropsy,   cough,   etc.). 

(4)  Intensity  of  Mtirmurs. — Sometimes  murmurs  are  so  loud 
that  they  are  audible  to  the  patient  himself  or  even  at  some  dis- 
tance from  the  chest.     In  one  case  I  was  able  to  hear  a  murmur 


184  PHYSICAL  DIAGNOSIS 

eight  feet  from  the  patient.  Such  cases  are  rare  and  usually  not 
serious,  for  the  gravity  of  the  lesion  is  not  at  all  proportional  to 
the  loudness  of  the  murmur;  indeed,  other  things  being  equal,  loud 
murmurs  are  less  serious  than  faint  ones,  provided  we  are  sure  we  are 
dealing  with  organic  lesions.  (On  the  distinction  between  the  organic 
and  functional  murmurs,  see  below,  p.  i88.) 

A  loud  murmur  means  a  powerful  heart  driving  the  blood  strongly 
over  the  diseased  valve.  When  the  heart  begins  to  fail,  the  intensity 
of  the  murmur  proportionately  decreases  because  the  blood  does  not 
flow  swiftly  enough  over  the  diseased  valve  to  produce  as  loud  a  sound 
as  formerly.  The  gradual  disappearance  of  a  murmur  known  to  be 
due  to  a  valvular  lesion  is,  therefore,  a  very  grave  sign,  and  its  reap- 
pearance revives  hope.  Patients  are  not  infrequently  admitted  to  a 
hospital  with  valvular  heart  trouble  which  has  gone  on  so  long  that 
the  muscle  of  the  heart  is  no  longer  strong  enough  to  produce  a  mur- 
mur as  it  pumps  the  blood  over  the  diseased  valve.  In  such  a  case, 
under  the  influence  of  rest  and  cardiac  tonics,  one  may  observe  the 
development  of  a  murmur  as  the  heart  wall  regains  its  power,  and 
the  louder  the  murmur  becomes  the  better  the  condition  of  the  patient. 
On  the  other  hand,  when  the  existence  of  a  valvular  lesion  has  been 
definitely  determined,  and  yet  the  compensation  remains  perfectly 
good  (for  example,  in  the  endocarditis  occurring  in  children  in  con- 
nection with  chorea),  an  increase  in  the  loudness  of  the  murmur  may 
run  parallel  with  the  advance  in  the  valvular  lesion. 

In  general  the  most  important  point  about  the  intensity  of  a 
murmur  is  its  increase  or  decrease  while  tinder  observation,  and  not 
its  loudness  at  any  one  time. 

(5)  Quality  of  Heart  Murmurs. — It  has  been  already  mentioned 
that  the  quality  of  a  heart  murmur  is  never  anything  like  the  sound 
which  we  ordinarily  designate  by  the  word  "murmur."  The  com- 
monest type  of  heart  murmur  has  a  blowing  quality,  whence  the  old 
name  of  ''bellows  sound."  The  sound  of  the  letter  "f"  prolonged  is 
not  unlike  the  quality  of  certain  murmurs.  Blowing  murmurs  may 
be  low-pitched  like  the  sound  of  air  passing  through  a  large  tube, 
or  high-pitched  approaching  the  sound  of  a  whistle.  This  last  type 
merges  into  that  known  as  the  musical  murmur,  in  which  there 
is  a  definite  musical  sound  whose  pitch  can  be  identified.  Rasping 
or  tearing  sounds  often  characterize  the  louder  varieties  of  murmurs. 

Finally,  there  is  one  type  of  sound  which,  though  included  under 
the  general  name  murmur,  differs  entirely  from  any  of  the  other 
sounds  just  described.     This  is  the  "presystolic  roll,"  which   has  a 


AUSCULTATIOX  OF  THE  HEART  185 

rumbling  or  blubbering  quality  or  may  remind  one  of  a  short  drum- 
roll.  This  murmur  is  always  presystolic  in  time  and  usually  associated 
with  obstruction  at  the  mitral  or  tricuspid  valves.  Not  infrequently 
some  part  of  a  cardiac  murmur  will  have  a  musical  quality  while  the 
rest  is  simply  blowing  or  rasping  in  character.  Musical  murmurs 
do  not  give  us  evidence  either  of  an  especially  serious  or  especially 
mild  type  of  disease.  Their  chief  importance  consists  in  the  fact 
that  they  rarely  exist  without  some  valve  lesion/  and  are,  therefore, 
of  use  in  excluding  the  type  of  murmur  known  as  '^ ftmctional ,"  pres- 
ently to  be  discussed,  and  not  due  to  valve  disease.  Very  often 
rasping  murmurs  are  associated  either  with  the  calcareous  deposit 
upon  a  valve  or  very  marked  narrowing  of  the  valve  orifice. 

Murmurs  may  be  accented  at  the  beginning  or  the  end;  that  is, 
they  may  be  of  the  crescendo  type,  growing  louder  toward  the  end, 
or  of  the  decrescendo  type  with  their  maximum  intensity  at  the 
beginning.  Almost  all  murmurs  are  of  the  latter  type  except  those 
associated  with  mitral  or  tricuspid  obstruction. 

(6)  Length  of  A'hirmurs. — Murmurs  may  occupy  the  whole  of 
systole,  the  whole  of  diastole,  or  only  a  portion  of  one  of  these  periods, 
'but  no  conclusions  can  be  drawn  as  to  the  severity  of  the  valve  lesion 
from  the  length  of  the  murmur.  A  short  murmur,  especially  if 
diastolic,  may  be  of  very  serious  prognostic  import. 

(7)  Relations  to  the  Normal  Sounds  of  the  Heart. — Cardiac  murmurs 
may  or  may  not  replace  the  normal  heart  sounds.  They  may  occur 
simultaneously  with  one  or  both  sounds  or  between  the  soimds.  These 
facts  have  a  certain  amount  of  significance  in  prognosis.  Murmurs 
which  entirely  replace  cardiac  sounds  usually  mean  a  severer  disease 
of  the  affected  valve  than  murmurs  which  accompany,  but  do  not 
replace,  the  normal  heart  sounds.  Late  systolic  murmurs,  which 
occur  between  the  first  and  the  second  sound,  are  usually  associated 
with  a  relatively  slight  degree  of  valvular  disease.  Late  diastolic 
murmurs,  on  the  other  hand,  have  no  such  favorable  significance. 

(8)  Effects  of  Position,  Exercise,  and  Respiration  upon  Cardiac 
Murmurs. — Almost  all  cardiac  murmurs  are  affected  to  a  greater  or 
less  extent  by  the  position  which  the  patient  assumes  while  he  is 
examined.  Systolic  murmurs  which  are  inaudible  while  the  patient 
is  in  a  sitting  or  standing  position  may  be  quite  easily  heard  when  the 
patient  lies  down.  On  the  other  hand,  a  presystolic  roll  which  is 
easily  heard  when  the  patient  is  sitting  up  may  entirely  disappear 
when  he  lies  down.     Diastolic  murmurs  are  relatively  little  affected 

^  Rosenbach  holds  that  they  may  be  produced  by  adhesive  pericarditis. 


186  PHYSICAL  DIAGNOSIS 

by  the  position  of  the  patient,  but  in  the  majority  of  cases  are  some- 
what louder  in  the  upright  position. 

The  effects  of  exercise  may  perhaps  be  fitly  mentioned  here. 
Feeble  murmurs  may  altogether  disappear  when  the  patient  is  at  rest, 
and  under  such  circumstances  may  be  made  easily  audible  by  getting 
the  patient  to  walk  briskly  up  and  down  the  room  a  few  times.  Such 
lesions  are  usually  comparatively  slight.^  On  the  other  hand,  mur- 
murs which  become  more  marked  as  a  result  of  rest  are  generally  of 
the  severest  type  (see  above,  p.  184). 

Organic  murmurs  are  usually  better  heard  at  the  end  of  expiration 
and  become  fainter  during  inspiration  as  the  expanding  lung  covers 
the  heart.  This  is  especially  true  of  those  produced  at  the  mitral 
valve,  and  is  in  marked  contrast  with  the  variations  of  functional  mur- 
murs which  are  heard  chiefly  or  exclusively  at  the  end  of  inspiration. 

(9)  Sudden  Metamorphosis  of  Murmurs. — In  acute  endocarditis, 
when  vegetations  are  rapidly  forming  and  changing  their  shape  upon 
the  valves,  murmurs  may  appear  and  disappear  very  suddenly.  This 
metamorphosing  character  of  cardiac  murmurs,  when  taken  in  connec- 
tion with  other  physical  signs,  may  be  a  very  important  factor  in  the 
diagnosis  of  acute  endocarditis.  In  a  similar  way  relaxation  or 
rupture  of  one  of  the  tendinous  cords,  occurring  in  the  course  of  acute 
endocarditis,  may  effect  a  very  sudden  change  in  the  auscultatory 
phenomena. 

' '  Functional  Murmurs. ' ' 

Not  every  murmur  which  is  to  be  heard  over  the  heart  points  to 
disease  either  in  the  valves  or  in  the  orifices  of  the  heart.  Perhaps  the 
majority  of  all  murmurs  are  thus  unassociated  with  valvular  disease, 
and  to  such  the  name  of  "accidental,"  "functional,"  or  "hgemic" 
murmurs  has  been  given.  The  origin  of  these  "functional"  murmurs 
has  given  rise  to  an  immense  amount  of  controversy,  and  it  cannot  be 
said  that  any  one  explanation  is  now  generally  agreed  upon.  To  me 
the  most  plausible  view  is  that  which  regards  most  of  them  as  due 
either  to  a  temporary  or  permanent  dilatation  of  the  conus  arteriosus, 
or  to  pressure  or  suction  exerted  upon  the  overlapping  lung  margins  by 
the  cardiac  contractions.  This  explains  only  the  systolic  functional 
murmurs,  which  make  up  ninety-nine  per  cent,  of  all  functional 
murmurs.  The  diastolic  functional  murmurs,  which  undoubtedly  oc- 
cur, although  with  exceeding  rarity,  are  probably  due  to  stretching  of 

'  For  exception  to  this  see  below,  page  205. 


AUSCULTATION  OF  THE  HEART  187 

the  aortic  ring  or  to  sounds  produced  in  the  veins  of  the  neck  and 
transmitted  to  the  vena  cava. 

Characteristics  of  Ftmctional  Murmurs. — (i)  Almost  all  functional 
murmurs  are  systolic,  as  has  before  been  mentioned. 

(2)  The  vast  majority  of  them  are  heard  best  over  the  pulmonic 
valve  in  the  second  left  intercostal  space.  From  this  point  they  are 
transmitted  in  all  directions,  and  are  frequently  to  be  heard,  although 
with  less  intensity,  in  the  aortic  and  mitral  areas.  Occasionally  they 
may  have  their  maximum  intensity  in  one  of  the  latter  positions. 

(3)  As  a  rule,  they  are  very  soft,  short,  and  blowing  in  quality, 
though  exceptionally  they  may  be  loud  and  rough.  They  almost 
never  extend  through  the  whole  of  systole. 

(4)  They  are  not  associated  with  any  evidence  of  enlargement  of 
the  heart  nor  with  accentuation  of  the  pulmonic  second  sound. ^ 

(5)  They  are  usually  louder  at  the  end  of  inspiration. 

(6)  They  are  usually  heard  over  a  very  limited  area  and  not 
transmitted  to  the  left  axilla  or  to  the  back. 

(7)  They  are  especially  evanescent  in  character;  for  example,  they 
may  appear  at  the  end  of  a  hard  run  or  boat  race  or  during  an  attack 
of  fever,  and  disappear  within  a  few  days  or  hours.  Respiration, 
position,  and  exercise  produce  greater  variations  in  them  than  in 
"organic"  murmurs. 

(8)  They  are  especially  apt  to  be  associated  with  anoemia,  although 
the  connection  between  anaemia  and  functional  heart  murmurs  is  by 
no  means  as  close  as  has  often  been  supposed.  The  severest  types  of 
anaemia,  for  example  pernicious  anaemia,  may  not  be  accompanied  by 
any  murmur,  while,  on  the  other  hand,  typical  functional  murmurs  are 
often  heard  in  patients  whose  blood  is  normal,  and  even  in  full  health. 
Yet  in  three  cases  of  intense  anaemia  I  have  heard  diastolic  murmurs 
loudest  at  the  fourth  left  costal  cartilage  and  leading  to  a  diagnosis  of 
aortic  regurgitation.  At  autopsy  the  aortic  valves  were  in  each  case 
sound,  and  I  am  at  a  loss  to  account  for  the  murmurs.-  It  should 
not  be  forgotten  that  a  real,  though  temporary,  leakage  through  the 
mitral  or  tricuspid  valve  may  be  associated  with  anaemia  or  debilitated 
conditions  owing  to  weakening  of  the  papillary  muscles  or  of  the  mitral 
sphincter.  In  such  cases  we  find  not  the  signs  of  a  functional  murmur, 
as  above  described,  but  the  evidence  of  an  organic  valve  lesion  here- 
after to  be  described. 

'  In  chlorosis  the  second  pulmonic  sound  is  often  very  loud  (owing  to  the  retraction 
of  the  lungs  and  uncovering  of  the  conus  arteriosus)  and  associated  with  a  systoUc  murmur. 
^  Cabot  and  Locke:  Johns  Hopkins  Bulletin,  May,  1903. 


188  PHYSICAL  DIAGNOSIS 

The  distinctions  between  organic  and  functional  heart  murmurs 
may  be  summed  up  as  follows : 

Organic  murmurs  may  occupy  any  part  of  the  cardiac  cycle;  if 
systolic,  they  are  often  transmitted  either  into  the  axilla  and  back  or 
into  the  great  vessels  of  the  neck;  they  are  usually  associated  with 
evidences  of  cardiac  enlargement  and  changes  in  the  second  sounds 
at  the  base  of  the  heart,  as  well  as  with  signs  and  symptoms  of  stasis 
in  other  organs.  Organic  murmurs  not  infrequently  have  a  musical 
or  rasping  quality,  although  this  is  by  no  means  always  the  case. 
They  are  rarely  loudest  in  the  pulmonic  area  and  are  relatively  unin- 
fluenced by  respiration,  position,  or  exercise. 

Functional  miirmurs  are  almost  always  systolic  in  time  and  usually 
heard  with  maximum  intensity  in  the  pulmonic  area.  They  are 
rarely  transmitted  beyond  the  precordial  region  and  are  usually  loudest 
at  the  end  of  inspiration.  They  are  not  accompanied  by  evidences  of 
cardiac  enlargement  or  pathological  accentuation  of  the  second 
sounds  at  the  base  of  the  heart,  nor  by  signs  of  venous  stasis  or  dropsy. 
They  are  very  apt  to  be  associated  with  anaemia  or  with  some  special 
attack  upon  the  resources  of  the  body  (e.g.,  physical  overstrain  or 
fever),  and  to  disappear  when  such  forces  are  removed.  They  are 
usually  short  and  soft  in  quality;  never  musical.  The  very  rare 
diastolic  functional  murmur  occurs  exclusively,  so  far  as  I  am  aware, 
in  conditions  of  profound  anaemia;  i.e.,  when  the  haemoglobin  is  twenty- 
five  per  cent,  or  less.  It  can  sometimes  be  abolished  by  pressing  the 
jugular  bulb  and  can  then  be  observed,  if  followed  to  the  neck,  to  pass 
over  gradually  into  a  continuous  venous  hum  with  a  diastolic  accent. 

Cardio- Respiratory  Murmurs. 

When  a  portion  of  the  free  margin  of  the  lung  is  fixed  by  adhesions 
in  a  position  overlapping  the  heart,  the  cardiac  movements  may 
rhythmically  displace  the  air  in  such  piece  of  lung  so  as  to  give  rise  to 
sounds  which  at  times  closely  simulate  cardiac  murmurs.  These 
conditions  are  most  often  to  be  found  in  the  tongue-like  projection  of 
the  left  lung,  which  normally  overlaps  the  heart,  but  it  is  probably 
the  case  that  cardio-respiratory  murmurs  may  be  produced  without 
any  adhesion  of  the  lung  to  the  pericardium  under  conditions  not  at 
present  understood.  Such  murmurs  may  be  heard  under  the  left 
clavicle  or  below  the  angle  of  the  left  scapula,  as  well  as  near  the  apex 
of  the  heart, — less  often  in  other  parts  of  the  chest. 

Cardio-respiratory  murmurs  may  be  either  systolic  or  diastolic, 
but  the  vast  majority  of  cases  are  systolic.     The  area  over  which  they 


AUSCULTATION  OF  THE  HEART  189 

are  audible  is  usually  a  very  limited  one.  They  are  greatly  affected 
by  position  and  by  respiration,  and  are  heard  most  distinctly  if  not 
exclusively  during  inspiration,  especially  at  the  end  of  that  act. 
(This  fact  is  an  important  aid  in  distinguishing  them  from  true  cardiac 
murmurs,  which  are  almost  always  fainter  at  the  end  of  inspiration.) 
They  are  also  greatly  affected  by  cough  or  forced  respiration  or  by 
holding  the  breath,  whereas  cardiac  murmurs  are  relatively  little 
changed  thereby.  Pressure  on  the  outside  of  the  thorax  and  in  their 
vicinity  may  greatly  modify  their  intensity  or  quality,  while  organic 
cardiac  murmurs  are  less  influenced  by  pressure.  As  a  rule,  they  have 
the  quality  of  normal  respiratory  murmur,  and  sound  like  an  inspiration 
interrupted  by  each  diastole  of  the  heart} 

In  case  the  effect  of  the  cardiac  movements  is  exerted  upon  a  piece 
of  lung  in  which  a  catarrhal  process  is  going  on,  we  may  have  systolic 
or  diastolic  crackles  or  squeaks,  or  any  type  of  respiratory  murmur 
except  the  bronchial  type,  since  this  is  produced  in  solid  lung  which 
could  not  be  emptied  or  filled  under  the  influence  of  the  cardiac  move- 
ments. Cardio-respiratory  murmurs  have  no  special  diagnostic 
significance,  and  are  mentioned  here  only  on  account  of  the  importance 
of  not  confusing  them  with  true  cardiac  murmurs.  They  were 
formerly  thought  to  indicate  phthisis,  but  such  is  not  the  case. 

Mtirmurs  of  Venous  Origin. 

I  have  already  mentioned  that  the  venous  hum  so  often  heard  in 
the  neck  in  cases  of  anaemia  may  be  transmitted  to  the  region  of  the 
base  of  the  heart  and  heard  there  as  a  diastolic  murmur  owing  to  the 
acceleration  of  the  venous  current  by  the  aspiration  of  the  right 
ventricle  during  diastole.  Such  murmurs  are  very  rare  and  may 
usually  be  obliterated  by  pressure  upon  the  bulbous  jugularis,  or  even 
by  the  compression  brought  to  bear  upon  the  veins  of  the  neck  when 
the  head  is  sharply  turned  to  one  side.  They  are  heard  better  in  the 
upright  position  and  during  inspiration. 

Arterial  Murmurs. 

(i)  Roughening  or  slight  dilatation  of  the  arch  of  the  aorta,  due  to 
chronic  endaortitis,  is  a  frequent  cause  in  elderly  men  of  a  systolic 
murmur,  heard  best  at  the  base  of  the  heart  and  transmitted  into  the 
vessels  of  the  neck.  Such  a  murmur  is  very  rarely  accompanied  by  a 
palpable  thrill.     From  cardiac  murmurs  it  is  distinguished  by  the  lack 

^  For  the  distinction  from  cog-wheel  breathing,  see  above,  page  153. 


190  PHYSICAL  DIAGNOSIS 

of  any  other  evidence  of  cardiac  disease  and  the  presence  of  marked 
arterio-sclerosis  in  the  peripheral  vessels  (see  further  discussion  under 
Aortic  Stenosis,  p.  227,  and  under  Aneurism,  p.  264). 

(2)  A  narrowing  of  the  lumen  of  the  subclavian  artery,  due  to 
some  abnormality  in  its  course,  may  give  rise  to  a  systolic  murmur 
heard  close  below  the  clavicle  at  its  outer  end.  The  murmur  is  greatly 
influenced  by  movements  of  the  arm  and  especially  by  respiratory 
movements.  During  inspiration  it  is  much  louder,  and  at  the  end  of 
a  forced  expiration  it  may  disappear  altogether.  Occasionally  such 
murmurs  are  transmitted  through  the  clavicle  so  as  to  be  audible  above 
it. 

(3)  Pressure  exerted  upon  any  of  the  superficial  arteries  (carotid, 
femoral,  etc.)  produces  a  systolic  murmur  (see  below,  p.  224).  Dias- 
tolic arterial  murmurs  are  peculiar  to  aortic  regurgitation. 

(4)  Over  the  anterior  fontanelle  in  infants  and  over  the  gravid 
uterus  systolic  murmurs  are  to  be  heard  which  are  probably  arterial 
in  origin. 

(5)  Thayer  has  recently  described  an  epigastric  murmur  in  a  case 
of  cirrhotic  liver. 


CHAPTER  XI. 
DISEASES  OF  THE  HEART. 

VALVULAR  LESIONS. 

Clinically  it  is  convenient  to  divide  the  ills  which  befall  the  heart 
into  three  classes: 

(i)   Those   which   deform   the   cardiac   valves    (valvular   lesions). 

(2)  Those  which  weaken  the  heart  wall  (parietal  disease). 

(3)  Congenital  malformations. 

Lesions  which  affect  the  cardiac  valves  without  deforming  them 
are  not  often  recognizable  during  life.  The  vegetations  of  acute 
endocarditis  often  do  not  produce  any  peculiar  physical  signs  until 
they  have  so  far  deformed  or  obstructed  the  valves  as  to  prevent  their 
opening  or  closing  properly. 

The  murmurs  which  are  often  heard  over  the  heart  in  cases  of  acute 
articular  rheumatism  cannot  be  considered  as  evidence  of  vegetative 
endocarditis  unless  an  access  of  fever  and  leucocytosis,  some  evidence 
of  embolism  or  some  valvular  deformities,  with  their  results  in  valvu- 
lar obstruction  or  incompetency,  ensue.  The  chordae  tendineae  may 
be  ruptured  or  shortened,  thickened,  and  welded  together  into  shape- 
less masses,  but  if  these  deformities  do  not  affect  the  action  of  the 
valves  we  have  no  means  of  recognizing  them  during  life.  Congenital 
malformations  are  practically  unrecognizable  as  such.  If  they  do  not 
affect  the  valves,  we  cannot  with  any  certainty  make  out  what  is 
wrong. 

For  physical  diagnosis,  then,  heart  disease  means  either  deformed 
valves  or  weakened  walls.  I  include  here,  under  the  results  of  weak- 
ened walls,  all  the  disorders  of  conduction  and  rhythm  described  on 
pages  244  to  250.  Whatever  else  may  exist,  we  are  none  the  wiser 
for  it  unless  the  autopsy  enlightens  us. 

In  this  chapter  I  shall  confine  myself  to  the  discussion  of  valvular 
lesions  and  their  results. 

Valvular  lesions  are  of  two  types : 

(a)  Those  which  produce  partial  obstruction  of  a  valve  orifice  or 
prevent  its  opening  fully  {"stenosis"). 

191 


192 


PHYSICAL  DIAGNOSIS 


(&)  Those  which  produce  leakage  through  a  valve  orifice  or  prevent 
its  closing  efifectively  ("regurgitation,"  "insufficiency,"  "incompetency"). 

Stenosis  results  always  from  the  stiffening,  thickening,  and  con- 
traction of  a  valve. 

Regurgitation,  on  the  other  hand,  may  be  the  result  either  of — 

(a)  Deformity  of  a  valve,  or 

(b)  Weakening  of  the  heart  muscle. 


\  Valynla    semttunaris 

'  ^        "      posterior  aortac 


v^ T posterior  ' 

I  I        Aannlus  fihrosas 


Fig.  139. — The  Base  of  the  Contracted  Heart  Showing  Sphincteric  Action  of  the  Mus- 
cular Fibres  Surrounding  the  Mitral  and  Tricuspid  Valves.  The  outer  dotted  line  is  the 
outline  of  the  relaxed  heart.  The  inner  dotted  circles  show  the  size  of  the  mitral  and 
tricuspid  valves  during  diastole,  a,  Outline  of  the  heart  when  relaxed;  b,  outline  of  the 
relaxed  tricuspid  valve;  c,  outline  of  the  mitral  orifice  during  diastole.     (After  Spalteholz.) 


The  mitral  and  tricuspid  orifices  are  closed  not  simply  by  the 
shutting  of  their  valves,  but  also  in  part  by  the  sphincter-like  action 
of  the  circular  fibres  of  the  heart  wall  (see  Fig.  139)  and  the  contraction 
of  the  papillary  muscles  (Fig.  140). 

In  birds  the  tricuspid  orifice  has  no  valve  and  is  closed  wholly  by 
the  muscular  sphincter  of  the  heart  wall. 

In  conditions  of  very  acute  cardiac  failure,  such  as  may  occur 
after  a  hard  run,  the  papillary  muscles  are  in  all  probability  relaxed, 


VALVULAR  LESIONS 


193 


Papillary 
muscle. 


SO    that    the    valve-flaps    swing    back    into   the   auricle   and   permit 
regurgitation  of  blood  from  the  ventricle. 

Valvular  incompetence,  then,  differs  from  valvular  obstruction 
in  that  the  latter  always  involves  deformity  and  stiffening  of  valves, 
while  incompetence  or  leakage  is  often  the  result  of  deficient  muscular 
action  on  the  part  of  the  heart  wall.  An  obstructed  valve  is  almost 
always  leaky  as  well,  since  the  same  deformities  which  prevent  a 
valve  from  opening  usually  prevent  its  closure;  but  this  rule  does  not 
work  backward.     A  leaky  valve  is  often  not  obstructed.     It  is  leaky 

Mitral  curtains. 


Circular     or 
-    sphincteric 
fibres. 


Endocardium. 


■  Myocardium. 


Pericardium. 


Fig.  140. — The  Mitral  Valve  Closed,  Showing  the  Action  of  the  Papillary  Muscles.     (After 

Spalteholz.) 

but  not  obstructed  if  the  valve  curtain  has  been  practically  destroyed 
by  endocarditis;  or,  again,  it  is  leaky  but  not  obstructed  if  the  leak 
represents  muscular  weakening  of  the  mitral  sphincter  or  of  the  papil- 
lary muscles.  Pure  stenosis  is  very  rare.  Pure  regurgitation  is  very 
common,  especially  at  the  mitral. 

When  valves  are  so  deformed  that  their  orifice  is  both  leaky  and 
obstructed,  we  have  what  is  known  as  a  "combined"  or  "double" 
valve  lesion. 

Since  valvular  lesions  are  recognized  largely  by  their  results,  first 
upon  the  walls  of  the  heart  itself  and  then  upon  the  other  organs  of 
the  body,  it  seems  best  to  give  some  account  of  these  results  before 
passing  on  to  the  description  of  the  individual  lesions  in  the  heart 
itself. 

13 


194  PHYSICAL  DIAGNOSIS 

The  results  of  valvular  lesions  are  first  conservative  and  later  de- 
structive.    The  conservative  results  are  known  as: 

The  establishment  of  compensation  through  hypertrophy. 

The  destructive  or  degenerative  results  are  known  as: 

The  failure  of  compensation  through   (or  without)   dilatation. 

I  shall  consider,  then, 

(a)   The  establishment  and  the  failure  of  compensation. 

(6)    Cardiac  hypertrophy. 

(c)    Cardiac  dilatation. 

Establishment     and     Failure    of    Compensation  in    Valvular 
Disease  of  the  Heart. 

We  may  discriminate  three  periods  in  the  progress  of  a  case  of 
valvular  heart  disease : 

(i)   The  period  before  the  establishment  of  compensation. 

(2)  The  period  of  compensation. 

(3)  The  period  of  failing  or  ruptured  compensation. 

(i)    Compensation  Not  Yet  Established. 

In  most  cases  of  acute  valvular  endocarditis,  whether  of  the 
relatively  benign  or  of  the  malignant  type,  there  is  a  time  when  the 
lesion  is  perfectly  recognizable  despite  the  fact  that  compensatory 
hypertrophy  has  not  yet  occurred.  In  some  cases  this  period  may  last 
for  months;  the  heart  is  not  enlarged,  there  is  no  accentuation  of  either 
second  sound  at  the  base,  there  is  no  venous  stasis,  and  our  diagnosis 
must  rest  solely  upon  the  presence  and  characteristics  of  the  murmur. 
For  example,  in  early  cases  of  mitral  regurgitation  due  to  chorea  or 
rheumatism,  the  disease  may  be  recognized  by  the  presence  of  a 
long  or  musical  murmur  heard  in  the  back  as  well  as  at  the  apex  and 
in  the  axilla.  In  the  earlier  stages  of  aortic  regurgitation  occurring 
in  young  people  as  a  complication  of  rheumatic  fever,  there  may  de 
absolutely  no  evidence  of  the  valve  lesion  except  the  characteristic 
diastolic  murmur. 

(2)    The  Period  of  Compensation.  * 

Valvular  disease  would,  however,  soon  prove  fatal  were  it  not  for 
the  occurrence  of  compensatory  hypertrophy  of  the  heart  walls.  To 
a  certain  extent  the  heart  contracts  as  a  single  muscle,  and  increases 
the  size  of  all  its  walls  in  response  to  the  demand  for  increased  work ; 
but  as  a  rule  the  hypertrophy  affects  especially  one  ventricle — that 
ventricle,  namely,  upon  which  especially  demand  is  made  for  increased 


VALVULAR  LESIONS  195 

power  in  order  to  overcome  an  increased  resistance  in  the  vascular  cir- 
cuit which  it  suppHes  with  blood.  Whatever  increases  the  resistance 
in  the  lungs  brings  increased  work  upon  the  right  ventricle ;  whatever 
increases  the  resistance  in  the  aorta  or  peripheral  arteries  increases 
the  amount  of  work  which  the  left  ventricle  must  do. 

Now,  any  disease  of  the  mitral  valve,  whether  obstruction  or 
leakage,  results  in  engorgement  of  the  lungs  with  blood,  and  hence 
demands  an  increased  amount  of  work  on  the  part  of  the  right  ventricle 
in  order  to  force  the  blood  through  the  overcrowded  pulmonary 
vessels;  hence  it  is  in  mitral  disease  that  we  find  the  greatest  com- 
pensatory hypertrophy  of  the  right  ventricle. 

On  the  other  hand,  it  is  obvious  that  obstruction  at  the  aortic 
valves  or  in  the  peripheral  arteries  (arterio-sclerosis,  nephritis) 
demands  an  increase  in  power  in  the  left  ventricle,  in  order  that  the 
requisite  amount  of  blood  may  be  forced  through  arteries  of  reduced 
calibre,  while  if  the  aortic  valve  is  so  diseased  that  a  part  of  the  blood 
thrown  into  the  aorta  by  the  left  ventricle  returns  into  that  ventricle, 
its  work  is  thereby  greatly  increased,  since  it  has  to  contract  upon  a 
larger  volume  of  blood. 

In  response  to  these  demands  for  increased  work,  the  muscular 
wall  of  the  left  ventricle  increases  in  thickness,  and  compensation  is 
thus  established  at  the  cost  of  an  increased  amount  of  work  on  the 
part  of  the  heart. ^ 

(3)   Failure  of  Compensation. 

Sooner  or  later  in  the  vast  majority  of  cases  the  heart,  handi- 
capped as  it  is  by  a  leakage  or  obstruction  of  one  or  more  valves, 
becomes  unable  to  meet  the  demands  made  upon  it  by  the  needs  of 
the  circulation.  Failure  of  compensation  is  associated  with  decrease  of 
muscular  tone  and  thence  with  stretching  of  the  heart's  walls.  Not 
infrequently  recurrent  attacks  of  ^'failing  compensation"  represent  a 
flare-up  of  a  smouldering  endocarditis  as  the  accompanying  leucocytosis 
{with  or  without  fever)  suggests.  This  is  especially  common  in  children 
but  occurs  also  in  young  adults.  Sometimes,  however,  neither 
mechanical  nor  infectious  changes  can  be  found.  Whatever  the 
cause  may  be,  the  result  of  ruptured  compensation  is  venous  statis; 
that  is,  oedema  or  dropsy  of  various  organs  appears.  If  the  left 
ventricle  is  especially  weakened,  dropsy  appears  first  in  the  legs,  on 
account  of  the  influence  of  gravity,  soon  after  in  the  genitals,  lungs, 

^  Rosenbach  brings  forward  evidence  to  show  that  the  arteries,  the  lungs,  and  other 
organs  actively  assist  in  maintaining  compensation. 


196  PHYSICAL  DIAGNOSIS 

liver,  and  the  serous  cavities.  Engorgement  of  the  lungs  is  especially 
marked  in  cases  of  mitral  disease  with  weakening  of  the  right  ventricle, 
and  is  manifested  by  dyspnoea,  cyanosis,  cough,  and  haemoptysis. 
In  many  cases,  however,  dropsy  is  very  irregularly  and  unaccount- 
ably distributed,  and  does  not  follow  the  rules  just  given.  In  pure 
aortic  disease,  uncomplicated  by  leakage  of  the  mitral  valve,  dropsy 
is  a  relatively  late  symptom,  and  precordial  pain  (angina  pectoris)  is 
more  prominent. 

Functional  Tests  of  Compensation.. — After  a  considerable  trial  of 
the  methods  by  which  it  has  been  proposed  to  test  cardiac  power 
through  watching  the  heart's  response  to  measured  "doses"  of  work, 
I  am  convinced  that  the  best  tests  are  the  ordinary  duties  and  pleasures 
of  life  which  step  by  step  the  patient  naturally  tries  in  convalescence. 

Hypertrophy  and  Dilatation. 

Since  cardiac  hypertrophy  or  dilatation  are  not  in  themselves  dis- 
eases, but  may  occur  in  any  disease  of  the  heart  (valvular  or  parietal), 
it  seems  best  to  give  some  account  of  them  and  of  the  methods  by 
which  they  may  be  recognized,  before  taking  up  separately  the  different 
lesions  with  which  they  are  associated. 

Causes. 

1.  Vascular  hypertension   (nephritis,   arterio-sclerosis) . 

2.  Valvular  disease  (mostly  "rheumatic"). 

3.  Syphilitic  aortitis   (with  or  without  aneurism). 

4.  Adherent  pericardium. 

5.  Beer  drinking. 

6.  Severe    and    prolonged    muscular    exertion    (athlete's    heart). 
Moderate  hypertrophy  and  dilatation  are  often  found  in  Graves' 

disease  and  in  severe  anaemias. 

W.  T.  Howard's  classification  of  108  cases  of  cardiac  hypertrophy 
post  mortem  {Johns  Hopkins  Bull.,  1894,  iii,  266),  is  entirely  in  accord 
with  my  own  experience: 


Arterio-sclerosis 

Nephritis 

Valvular  heart  disease. 
Adherent  pericardium. 

Hard  work 

Tumors 

Aneurism 

Polycythaemia 


Cases. 

Per  cent. 

65 

59 

14 

13-4 

13 

12 

4 

8 

7 

6 

4 

3 

8 

2 

I 

9 

I 

95 

I 

95 

108 


VALVULAR  LESIONS  197 

In  valvular  disease  the  greatest  degree  of  hypertrophy  is  to  be 
seen  usually  in  relatively  young  persons,  and  especially  when  the 
advance  of  the  lesion  is  not  very  rapid. 

Hypertrophy  of  the  heart  in  valvular  disease  is  also  influenced  by 
the  amount  of  muscular  work  done  by  the  patient,  by  the  degree 
of  vascular  tension,  and  by  the  treatment.  In  the  great  majority 
of  cases  of  hypertrophy,  from  whatever  cause,  both  sides  of  the  heart 
are  affected,  but  we  may  distinguish  cases  in  which  one  or  the  other 
ventricle  is  predominantly  affected. 

Results. 
(i)    Cardiac  hypertrophy  affecting  especially  the  lejt  ventricle. 

(a)  High  systolic  blood  pressure  is  the  most  constant  and  reliable 
of  all  the  signs  of  cardiac  hypertrophy  and  is  therefore  mentioned  here. 

(b)  The  apex  impulse  is  usually  lower  than  normal,  often  in  the 
sixth  space,  occasionally  in  the  seventh  or  eighth.^  It  is  also  farther 
to  the  left  than  normal,  but  far  less  so  than  in  cases  in  which  the  hyper- 
trophy affects  especially  the  right  ventricle.  The  area  of  visible 
pulsation  is  usually  increased,  and  a  considerable  portion  of  the  chest 
wall  may  be  seen  to  move  with  each  systole  of  the  heart,  while  fre- 
quently there  is  a  systolic  retraction  of  the  interspaces  in  place  of  a 
systolic  impulse. 

(c)  Palpation  confirms  the  results  of  inspection  and  shows  us  also 
that  the  apex  impulse  is  unusually  deliberate  and  diffuse  as  well  as 
powerful  ("heaving  impulse").  Percussion  shows  in  many  cases  that 
the  cardiac  dulness  is  more  intense  and  its  area  increased  downward 
and  to  a  lesser  extent  toward  the  left.^ 

(d)  If  we  listen  in  the  region  of  the  maximum  cardiac  impulse,  we 
generally  hear  an  unusually  long  and  low-pitched  first  sound,  which 
may  or  may  not  be  of  a  greater  intensity  than  normal.  A  very  loud 
first  sound  is  much  more  characteristic  of  a  cardiac  weakness  or  neu- 
rosis than  of  pure  hypertrophy  of  the  left  ventricle. 

The  second  sound  at  the  apex  (the  aortic  second  sound  transmitted) 
is  usually  much  louder  and  sharper  than  usual.  Auscultation  in  the 
aortic  area  shows  that  the  second  sound  at  that  point  is  loud  and 
ringing  in  character.     Not  infrequently  the  peripheral  arteries  (the 

^  This  is  due  partly  to  a  stretching  of  the  aorta,  produced  by  the  increased  weight 
of  the  heart. 

-  Post  mortem  enlarged  left  ventricle  is  often  found  despite  the  absence  of  the  above 
signs  in  life  because  it  extends  backward  out  of  our  reach. 


198  PHYSICAL  DIAGNOSIS 

subclavians,  brachials,  carotids,  radials,  and  femorals)  may  be  seen  to 
pulsate  with  each  systole  of  the  heart.  This  sign  is  most  frequently 
observed  in  cases  of  hypertrophy  of  the  left  ventricle,  which  are  due 
to  aortic  regurgitation,  but  is  by  no  means  peculiar  to  this  disease  and 
may  be  repeatedly  observed  when  the  cardiac  hypertrophy  is  due  to 
arterio-sclerosis.  Graves'  disease,  anaemia,  or  muscular  work.  I  have 
frequently  observed  it  in  healthy  athletes. 

The  radial  pulse  wave  has  ho  constant  characteristics,  but  depends 
rather  upon  the  cause  which  has  produced  the  hypertrophy  than  upon 
the  hypertrophy  itself. 
(2)   Cardiac    Hypertrophy    Affecting    Especially    the    Right    Ventricle. 

It  is  much  more  difficult  to  be  certain  of  the  existence  of  enlarge- 
ment of  the  right  ventricle  than  of  the  left.  Practically  we  have  but 
two  reliable  physical  signs : 

(a)  Increase  in  the  transverse  diameter  of  the  heart,  as  shown  by 
the  position  of  the  apex  impulse  and  by  percussion  of  the  right  and  left 
borders  of  the  heart;  and 

(6)  Accentuation  of  the  pulmonic  second  sound,  which  is  often 
palpable  as  well  as  audible. 

The  apex  beat  is  displaced  both  to  the  left  and  downward,  hut 
especially  to  the  left.  In  cases  of  long-standing  mitral  disease,  the 
cardiac  impulse  may  be  felt  in  mid-axilla,  several  inches  outside  the 
nipple,  and  yet  not  lower  down  than  the  sixth  intercostal  space.  In  a 
small  percentage  of  cases  {i.e.,  when  the  right  auricle  is  engorged),  an 
increased  area  of  dulness  to  the  right  of  the  sternum  may  be  demon- 
strated. Accentuation  of  the  pulmonic  second  sound  is  almost 
invariably  present  in  hypertrophy  of  the  right  ventricle,  though  it  is 
not  peculiar  to  that  condition.  It  may  be  heard,  for  example,  in  cases 
of  pneumonia  when  no  such  hypertrophy  is  present,  but  in  the  vast 
majority  of  cases  of  cardiac  disease  we  may  infer  the  presence  and  to 
some  extent  the  amount  of  hypertrophy  of  the  right  ventricle  from 
the  presence  of  a  greater  or  lesser  accentuation  of  the  pulmonic  second 
sound.  The  radial  pulse  shows  nothing  characteristic  of  this  type  of 
hypertrophy. 

Epigastric  pulsation  gives  us  no  evidence  of  the  existence  of 
hypertrophy  of  the  right  ventricle,  despite  contrary  statements  in 
many  text-books.  Such  pulsation  is  frequently  to  be  seen  in  persons 
with  normal  hearts,  and  is  frequently  absent  when  the  right  ventricle 
is  obviously  hypertrophied.  It  is  perhaps  most  often  due  to  an 
unusually  low  position  of  the  whole  heart. 


VALVULAR  LESIONS 


199 


Dilatation  of  the  Heart. 

Dilatation  cannot  be  considered  as  an  unmixed  evil.  In  aortic 
regurgitation  and  most  other  types  of  cardiac  disease  it  is  inseparably- 
linked  with  hypertrophy  and  is  present  long  before  compensation 
fails.  Probably  it  is  the  predominance  of  dilatation  over  hypertrophy 
that  causes  stasis  and  the  other  abnormalities  next  to  be  described. 

(i)  Acute  Dilatation. — Immediately  after  severe  muscular  exertion, 
as,  for  example,  at  the  finish  of  a  boat  race,  or  of  a  two-mile  run 
(especially  in  persons  not  properly  trained) ,  an  acute  cardiac  dilatation 
is   said  to   occur   occasionally.     In   debilitated   or  poorly   nourished 


Fig.   141. — Dilated  Heart.     From  v.  Ziemssen's  Atlas. 


subjects  or  when  the  heart  has  been  previously  weakened  by  disease 
such  an  acute  dilatation  may  be  serious  or  even  fatal  in  its  results.  I 
have  never  seen  this  in  healthy  persons,  but  Hornung  {Berl.  klin. 
Woch.,  xlv,  1769)  believes  that  with  the  fiuoroscope  he  has  identified 
cases  of  acute  dilatation  in  healthy  persons  after  fright,  sexual  excite- 
ment, high  altitude,  and  other  strains. 

(2)  Chronic  dilatation  comes  on  gradually  as  a  result  of  valvular 
disease  or  other  cause,  and  gives  rise  to  practically  the  same  physical 
signs  as  those  of  acute  dilatation,  from  which  it  differs  chiefly  as  regards 
the  accompanying  physical  phenomena  and  the  prognosis.  Briefly 
stated,  the  signs  of  predominant  dilatation  of  the  heart,  whether  acute 
or  chronic,  are: 

(a)  Feebleness  and  irregularity  of  the  apex  impulse  and  of  the 
radial  impulse;  (6)  enlargement  of  the  heart,  as  indicated  by  inspection. 


200  PHYSICAL  DIAGNOSIS 

palpation,  and  percussion,  and  (sometimes)  (c)  murmurs  indicative 
of  stretching  of  one  or  another  of  the  valvular  orifices;  (d)  often 
presystolic  gallop  rhythm  (see  above,  p.  176);  (e)  evidence  of  stasis 
at  the  periphery. 

Predominant  Dilatation  of  the  Left   Ventricle. 

Inspection  shows  little  that  is  not  better  brought  out  by  palpation. 
Palpation  reveals  a  "flapping"  cardiac  impulse,  or  a  vague  shock  dis- 
placed both  downward  and  to  the  left  and  diffused  over  an  abnormally 
large  area  of  the  chest  wall.  Percussion  verifies  the  position  of  the 
cardiac  impulse  and  sometimes  shows  an  unusually  blunt  or  rounded 
outline  at  the  apex  of  the  heart. 

On  auscultation,  the  first  sound  is  usually  very  short  and  sharp,  but 
not  feeble  unless  it  is  accompanied  by  a  murmur.  In  case  the  mitral 
orifice  is  so  stretched  as  to  render  the  valve  incompetent,  or  in  case 
the  muscles  of  the  heart  are  so  fatigued  and  weakened  that  they  do 
not  assist  in  closing  the  mitral  orifice,  a  systolic  murmur  is  to  be  heard 
at  the  apex  of  the  heart.  This  murmur  is  transmitted  to  the  axilla 
and  back,  but  does  not  usually  replace  the  first  sound  of  the  heart. 
The  aortic  second  sound,  as  heard  in  the  aortic  area  and  at  the  apex, 
is  feeble.     Peripheral  blood-pressure  falls. 

Predominant  Dilatation  of  the  Right   Ventricle. 

The  failure  of  muscular  tone  is  shown  by  an  increase  in  the  area 
of  cardiac  dulness  to  the  right  of  the  sternum  (corresponding  to  the 
position  of  the  right  auricle),  by  feebleness  of  the  pulmonic  second 
sound  together  with  signs  of  congestion  and  engorgement  of  the  lungs, 
and  often  by  a  systolic  murmur  at  the  tricuspid  valve;  i.e.,  at  or  near 
the  root  of  the  ensiform  cartilage.  When  this  latter  event  occurs, 
one  may  have  also  systolic  pulsation  in  the  jugular  veins  and  in  the 
liver  (see  below,  p.  234). 

In  cases  of  acute  dilatation,  such  as  occur  in  infectious  fevers  or 
in  chronic  latent  myocardial  disease,  there  is  often  to  be  heard  a  systolic 
murmur  loudest  in  the  pulmonary  area  and  due  very  possibly  to  a 
dilatation  of  the  conus  arteriosus. 

The  diagnosis  of  dilatation  of  the  heart  seldom  rests  entirely  upon 
physical  signs  referable  to  the  heart  itself.  In  acute  cases  our  diagnosis 
is  materially  aided  by  a  knowledge  of  the  cause,  which  is  often  toler- 
ably obvious.  In  chronic  cases  the  best  evidence  of  dilatation  is  often 
that  furnished  by  the  venous  stasis  which  results  from  it. 


VALVULAR  LESIONS  201 

(4)  Chronic  Valvular  Disease. 

I.  Mitral  Regurgitation. 

The  commonest  and  probably  one  of  the  least  serious  of  valvular 
lesions  is  incompetency  of  the  mitral.     It  results  in  most  cases  from 


Fig.  142. — Normal  Heart  during  Systole.     Mitral  valve  closed;  blood  flowing  through  the 
open  aortic  valves  into  the  aorta. 


■J£(^'/tx/J^<!^<7/ 


Fig.  143. — ^Mitral  Regurgitation.     The  heart  is  in  systole  and  the  arrows  show  the  current 
flowing  back  in  the  left  auricle  as  well  as  forward  into  the  aorta. 

the  shortening,  stiffening,  and  thickening  of  the  valve  produced  by 
rheumatic  endocarditis  in  early  life.  It  is  the  lesion  present  in  most 
cases  of  chorea  (see  Figs.  142  and  143). 


202  PHYSICAL  DIAGNOSIS 

Temporary  and  curable  mitral  regurgitation  may  result  from  weak- 
ening of  the  heart  muscle,  which  normally  assists  in  closing  the  mitral 
orifice  through  the  sphincter-like  contraction  of  its  circular  fibres. 

Great  muscular  fatigue,  such  as  is  produced  by  a  hard  boat  race, 
may  result  in  a  temporary  relaxation  of  the  mitral  sphincter  or  of  the 
papillary  muscles  sufficient  to  allow  of  genuine  but  temporary  and 
curable  regurgitation  through  the  mitral  orifice.  In  conditions  of 
profound  nervous  debility,  excitement,  or  exhaustion,  similar  weak- 
ening of  the  cardiac  muscles  may  allow  of  a  leakage  through  the  mitral, 
which  ceases  with  the  removal  of  its  cause.  Stress  has  been  laid  upon 
these  points  by  DaCosta,  by  Prince,  and  recently  by  Arnold. 

Mitral  insufficiency  due  to  stretching  of  the  ring  into  which  the 
valve  is  inserted  occurs  not  infrequently  as  a  result  of  dilatation  of  the 
left  ventricle,  and  is  commonly  known  as  relative  insufficiency  of  the 
mitral  valve.  The  valve  orifice  can  enlarge,  the  valve  cannot,  and 
hence  its  curtains  are  insufficient  to  fill  up  the  dilated  orifice.  This 
type  of  mitral  insufficiency  frequently  results  from  aortic  regurgitation 
with  the  dilatation  of  the  left  ventricle  which  that  lesion  produces, 
and  from  chronic  nephritis  and  arterio-sclerosis,  which  weaken  the 
heart  wall  until  it  dilates  and  widens  the  mitral  orifice. 

The  results  of  any  form  of  mitral  leakage  occur  in  this  order: 

( 1 )  Dilatation  and  hypertrophy  of  the  left  auricle,  which  has  to  receive 
blood  both  from  the  lungs  and  through  the  leaky  mitral  from  the  left 
ventricle. 

(2)  The  overfilled  left  auricle  cannot  receive  the  blood  from  the 
lungs  as  readily  as  it  should;  hence  the  blood  "backs  up"  in  the  lungs 
and  thereby  increases  the  work  which  the  right  ventricle  must  do  in 
order  to  force  the  blood  through  them.  Thus  result  oedema  of  the 
lungs,  and — 

(3)  Hypertrophy  and  dilatation  of  the  right  ventricle,  which  in 
turn  becomes  sooner  or  later  overcrowded  so  that  the  tricuspid  valve 
gives  way  and  tricuspid  leakage  occurs. 

(4)  The  capacity  for  hypertrophy  possessed  by  the  right  auricle 
is  soon  exhausted,  and  we  get  then — 

(5)  General  venous  stasis,  which  shows  itself  first  as  systolic  pulsa- 
tion in  the  jugulars  and  in  the  liver  and  later  in  the  tissues  drained  by 
the  portal  and  peripheral  veins.  This  venous  stasis  increases  the 
work  of  the  left  ventricle,  and  so  we  get — 

(6)  Hypertrophy  and  dilatation  of  the  left  ventricle.  Hypertrophy 
of  the  left  ventricle  is  also  produced  by  the  increased  work  necessary 
to  maintain  some  vestige  of  sphincter  action  at  the  leaky  mitral  orifice. 


VALVULAR  LESIONS  203 

as  well  as  by  the  labor  of  contracting  upon  the  extra  quantity  of  blood 
delivered  to  it  by  the  enlarged  left  auricle. 

At  last  the  circle  is  complete.  Every  chamber  in  the  heart  is 
enlarged,  overworked,  and  failure  is  imminent. 

Returning  now  to  the  signs  of  mitral  regurgitation,  we  shall  find 
it  most  convenient  to  consider  first  the  type  of  regurgitation  produced 
by  rheumatism  and  resulting  in  thickening,  stiffening,  and  retraction 
of  the  valve. 

Physical  Signs. 
(a)   First    Stage — Prior    to    the    Establishment    of    Compensation. 

We  have  but  one  characteristic  physical  sign : 

A  systolic  murmur  heard  loudest  at  the  apex  of  the  heart,  trans- 
mitted to  the  back  (below  or  inside  the  left  scapula)  and  to  the  left 
axilla.  The  murmur  is  usually  long  and  sometimes  musical  in  char- 
acter; when  this  is  the  case  diagnosis  is  much  easier.  Systolic  musical 
murmurs  widely  transmitted  do  not  occur  without  valvular  leakage. 
Rosenbach  believes  that  adherent  pericardium  is  capable  of  producing 
such  a  murmur,  but  only,  if  I  understand  him  rightly,  in  case  there  is  a 
genuine  mitral  leakage  due  to  the  embarrassing  embrace  of  the  peri- 
cardium which  prevents  the  mitral  orifice  from  closing. 

"Functional"  or  "hgemic"  murmurs  are  usually  short,  are  rarely 
heard  in  the  back,  and  very  rarely,  if  ever,  have  a  musical  quality. 

Cases  of  mitral  regurgitation  are  not  very  often  seen  at  this  stage, 
but  in  acute  endocarditis  after  the  fever  and  anaemia  have  subsided, 
or  in  chorea,  such  a  murmur  may  exist  for  days  or  weeks  before  any 
accentuation  of  the  pulmonic  second  sound  or  any  enlargement  of 
the  heart  appears.  I  have  had  the  opportunity  of  verifying  the 
diagnosis  at  autopsy  in  many  such  cases. 

(6)   Second  Stage — Compensation  Established. 

As  long  as  compensation  remains  perfect,  the  only  evidence  of 
regurgitation  may  be  that  obtained  by  auscultation,  and  I  shall  ac- 
cordingly begin  with  this  rather  than  in  the  traditional  way  with 
inspection,  palpation,  and  percussion. 

The  distinguishing  auscultatory  phenomena  in  cases  of  well-com- 
pensated mitral  insufficiency  are: 

(a)  A  systolic  murmur  whose  maximum  intensity  is  at  or  near  the 
apex  impulse  of  the  heart,  but  which  is  also  to  be  heard  in  the  left 


204  PHYSICAL  DIAGNOSIS 

axilla  and  in  the  back  below  or  inside  the  angle  of  the  left  scapula 
(so  far  the  signs  are  those  of  the  first  stage,  above  described). 

(b)  A  pathological  accentuation  of  the  pulmonic  second  sound. 
This  is  the  minimum  of  evidence  upon  which  it  is  justifiable  to 

make  the  diagnosis  of  compensated  mitral  regurgitation.  In  the  vast 
majority  of  cases,  however,  our  diagnosis  is  confirmed  by  the  following 
additional  data: 

(c)  Enlargement  of  the  heart  as  shown  by  inspection,  palpation, 
and  percussion. 

The  pulse  in  well-compensated  cases  shows  no  considerable  ab- 
normality. When  compensation  begins  to  fail,  or  sometimes  before 
that  time,  the  most  characteristic  thing  about  the  pulse  is  its  marked 
irregularity  both  in  force  and  rhythm.  Such  irregularity,  though 
usually  of  the  "  absolute"  type  and  associated  with  auricular  fibrillation, 
is  at  once  more  common  and  less  serious  in  mitral  disease  than  in  that 
of  any  other  valve;  it  may  continue  for  years  and  be  compatible  with 
very  tolerable  health. 

Returning  now  to  the  details  of  the  sketch  just  given,  we  will  take 
up  first — 

(a)  The  Murmur. — In  children  the  murmur  of  mitral  regurgitation 
may  be  among  the  loudest  of  all  murmurs  to  be  heard  in  valvular 
disease,  but  this  does  not  necessarily  imply  that  the  lesion  is  a  very 


1st  1st 


I 


2nd 


2nd, 


Fig.  144. — Diagram  to  Represent  Systolic  Mitral  Murmur.  The  heavy  lines  represent 
the  normal  cardiac  sounds  and  the  light  lines  the  murmur,  which  in  this  case  does  not 
replace  the  first  sound  and  "tapers"  off  characteristically  at  the  end. 

severe  one.  A  murmur  which  grows  louder  under  observation  in  a 
well-compensated  valvular  lesion  may  mean  an  advance  of  the  disease, 
but  if  the  case  is  first  seen  after  compensation  has  failed  a  faint, 
variable  whiff  in  the  mitral  area  may  mean  the  severest  type  of  lesion. 
As  the  patient  improves  under  the  influence  of  rest  and  cardiac 
tonics,  such  a  murmur  may  grow  very  much  louder,  or  a  murmur 
previously  inaudible  may  appear. 

The  length  of  the  murmur  varies  in  different  cases,  but  as  a  rule  it  is 
longer  than  those  which  are  "functional"  in  origin.  It  rarely  ends 
abruptly,  but  usually  "tails  off"  at  the  end  of  stystole  (see  Fig.  144). 
Musical  murmurs  are  heard  more  often  in  mitral  regurgitation  than 


VALVULAR  LESIONS  205 

in  any  other  valve  lesion.  The  first  sound  of  the  heart  may  or  may 
not  be  replaced  by  the  murmur  (see  Fig.  145).  When  the  sound 
persists  and  is  heard  either  with  or  before  the  murmur,  one  can  infer 
that  the  lesion  is  relatively  slight  in  comparison  with  cases  in  which 
the  first  sound  is  wholly  obliterated.  Post- systolic  or  late  systolic 
murmurs,  which  are  occasionally  heard  in  mitral  regurgitation,  are 
said  to  point  to  a  relatively  slight  amount  of  disease  in  the  valve 
(see   Fig.    144).     Rosenbach   claims   that   the   late   systolic   murmur 

illllllUlni  ■  .  I IIIIIIIIIIHii  I  I  I  I 

Fig.  145. — Systolic  Mitral  Murmur  Replacing  the  First  Sound  of  the  Heart. 

is  always  due  to  organic  disease  of  the  valves  and  never  occurs  as  a 
functional  murmur. 

When  compensation  fails,  the  murmur  may  altogether  disappear 
for  a  time,  and  if  the  patient  is  then  seen  for  the  first  time  and  dies 
without  rallying  under  treatment,  it  may  be  impossible  to  make 
the  diagnosis. 

The  murmur  of  mitral  regurgitation  is  conducted  in  all  directions, 
but  especially  toward  the  axilla  and  to  the  back  {not  around  the  chest, 
but  directly).  In  the  latter  situation  it  is  usually  louder  than  it  is  in 
mid-axilla,  and  occasionally  it  is  heard  as  loudly  in  the  back  as  any- 


ist 

I 


1st 
2n(l  I  -nd 


Fig.  146. — Late  Systolic  Murmur.     The  first  sound  is  clear  and  an  interval  intervenes 
between  it  and  the  murmur. 

where  else.     This  is  no  doubt  owing  to  the  position  of  the  left  auricle 
and  the  direction  of  the  regurgitant  stream  (see  Figs.  147  and  148). 

(6)  After  compensation  is  established  and  as  long  as  it  lasts  an 
accentuation  of  the  pulmonic  second  sound  is  almost  invariably  to  be 
made  out,  and  may  be  so  marked  that  we  can  feel  and  see  it,  as  well 
as  hear  it.  Not  infrequently  one  can  also  see  and  feel  the  pulsation 
of  the  conus  arteriosus — not  the  left  auricle — in  the  second  and 
third  left  intercostal  space.  (It  may  be  well  to  mention  again  here 
that  by  accentuation  of  the  pulmonic  second  sound  one  does  not 
mean  merely  that  it  is  louder  or  sharper  in  quality  than  the  aortic 


206 


PHYSICAL  DIAGNOSIS 


second  sound,  since  this  is  true  in  the  vast  majority  of  cases  in  healthy 
individuals  under  thirty  years  of  age.  Pathological  accentuation 
of  the  pulmonic  second  sound  means  a  greater  intensity  of  the  sound 
than  we  have  a  right  to  expect  at  the  age  of  the  individual  in  question.) 


Pulmonic  second 
accented. 


Systolic  murmur 
loudest  here. 


Fig.  147. — Mitral  Regurgitation. 


The  murmur  is  heard  over  the  shaded  area  as  well  as 
in  the  back. 


Systolic  murmur.  '" 


Fig.  148.^ — Mitral  Regurgitation.     Murmur  heard  over  the  shaded  area. 


Occasionally  the  pulmonic  second  sound  is  loudly  reduplicated,  but 
as  a  rule  this  points  to  an  accompanying  stenosis  of  the  mitral  valve. 
At  the  apex  the  second  sound  {i.e.,  the  transmitted  aortic  second) 
is  feeble  or  even  wanting  altogether,  owing  to  the  relatively  small 
amount  of  blood  which  recoils  upon  the  aortic  valves. 


VALVULAR  LESIONS  207 

(c)  Enlargement  of  the  heart,  and  more  especially  of  the  right 
ventricle,  is  generally  to  be  made  out,  and  in  the  majority  of  cases  this 
enlargement  is  manifested  by  displacement  of  the  apex  impulse  both 
downward  and  toward  the  left,  but  more  especially  to  the  left.  Per- 
cussion confirms  the  results  of  inspection  and  palpation  regarding  the 
position  of  the  cardiac  impulse.  The  normal  substernal  dulness  is 
increased  in  intensity,  and  we  can  sometimes  demonstrate  an  enlarge- 
ment of  the  heart  toward  the  right  (see  Fig.  145). 

In  children  (in  whom  adhesive  pericarditis  often  complicates  the 
disease)  a  systolic  thrill  may  not  infrequently  be  felt  at  the  apex, 
and  the  precordia  may  be  bulged,  and  even  in  adults  such  a  systolic 
thrill  is  not  so  rare  as  some  writers  would  have  us  suppose. 

{d)  The  pulse,  as  said  above,  shows  nothing  characteristic  at  any 
stage  of  the  disease.  While  compensation  lasts,  there  is  usually  noth- 
ing abnormal  about  the  pulse,  although  it  may  be  somewhat  irregular 
in  force  and  rhythm,  and  may  be  weak  when  compared  to  the  powerful 
beat  at  the  apex  in  case  the  regurgitant  stream  is  a  very  large  one. 
Irregularity  at  this  period  is  less  common  in  pure  mitral  regurgitation 
than  in  cases  complicated  by  stenosis. 


(c)   Third  Stage — Failing  Compensation. 

When  compensation  begins  to  fail,  the  pulse  becomes  weak  and 
irregular,  and  many  heart  beats  fail  to  reach  the  wrist,  but  there  is 
still  nothing  characteristic  about  the  pulse,  which  differs  in  no  respect 
from  that  of  any  case  of  cardiac  weakness  of  whatever  nature. 

(e)  Evidence  of  venous  stasis,  first  in  the  lungs  and  later  in  the 
liver,  lower  extremities,  and  serous  cavities,  does  not  show  itself  so 
long  as  compensation  is  sufficient,  but  when  the  heart  begins  to  fail  the 
patient  begins  to  complain  not  only  of  palpitation  and  cardiac  distress, 
but  of  dyspnoea,  orthopnoea,  and  cough,  and  examination  reveals  a 
greater  or  lesser  degree  of  cyanosis  with  pulmonary  oedema  manifested 
by  crackling  rales  at  the  base  of  the  lungs  posteriorly,  and  possibly 
also  by  haemoptysis  or  by  evidences  of  hydrothorax  (see  below,  p.  308). 
If  compensation  is  not  re-established,  the  right  ventricle  dilates,  the 
tricuspid  becomes  incompetent,  the  liver  becomes  enlarged  and 
tender,  dropsy  becomes  general,  the  heart  and  pulse  become  more  and 
more  rapid  and  irregular,  the  heart  murmur  disappears  and  is  replaced 
by  a  confusion  of  short  valvular  sounds,  ''gallop  rhythm'''  or  ''delirium 
cordis,''  often  considerably  obscured  by  the  noisy,  labored  breathing 


208  PHYSICAL  DIAGNOSIS 

with  numerous  moist  rales.  In  a  patient  seen  for  the  first  time  in  such 
a  condition  diagnosis  may  be  impossible,  yet  mitral  disease  of  some 
type  may  usually  be  suspected,  since  murmurs  produced  at  the  aortic 
valve  are  not  so  apt  to  disappear  when  compensation  fails.  The 
relative  tricuspid  insufficiency  which  often  occurs  is  likely  to  manifest 
itself  by  an  enlargement  of  the  right  auricle,  sometimes  demonstrable 
by  percussion  and  later  by  venous  pulsation  in  the  neck  and  in  the  liver. 

(d)   Differential  Diagnosis . 

The  murmur  of  mitral  regurgitation  may  be  confused  with 
(i)   Tricuspid  regurgitation. 

(2)  Functional  murmurs. 

(3)  Stenosis  or  roughening  of  the  aortic  valves. 

(4)  Dilatation  or  aneurism  of  the  aortic  arch. 

(i)  The  post-mortem  records  of  the  Massachusetts  General 
Hospital  show  that  in  the  presence  of  a  murmur  due  to  mitral  regur- 
gitation it  is  very  easy  to  fail  altogether  to  recognize  a  tricuspid 
regurgitant  murmur.  Only  5  out  of  29  cases  of  tricuspid  regurgitation 
found  at  autopsy  were  recognized  by  the  presence  of  a  murmur  during 
life.  Allbutt's  figures  from  Guy's  Hospital  are  similar.  In  the  major- 
ity of  these  cases,  mitral  regurgitation  was  the  lesion  on  which  atten- 
tion was  concentrated  during  the  patient's  life.  This  is  all  the  more 
excusable  because  the  tricuspid  area  is  so  wide  and  uncertain.  Mur- 
murs produced  at  the  tricuspid  orifice  are  sometimes  heard  with  maxi- 
mum intensity  just  inside  the  apex  impulse,  and  if  we  have  also  a 
mitral  regurgitant  murmur,  it  may  be  impossible  under  such  circum- 
stances to  distinguish  it  from  the  tricuspid  murmur.  Sometimes  the 
two  are  of  different  pitch,  but  in  most  cases  tricuspid  regurgitation 
must  be  recognized  indirectly  if  at  all,  i.e.,  through  the  evidence  given 
by  venous  pulsation  in  the  jugular  veins  and  in  the  liver,  and  through 
the  rapid  accumulation  of  ascites  and  oedema  of  the  leg. 

(2)  "Functional"  murmurs  are  usually  systolic  and  may  have 
their  maximum  intensity  at  the  apex  of  the  heart,  but  in  the  great 
majority  of  cases  they  are  heard  best  over  the  pulmonic  valve  or  just 
inside  or  outside  the  apex  beat  (Potain) .  They  are  faint  or  inaudible 
at  the  end  of  expiration,  and  are  more  influenced  by  position  than 
organic  murmurs  are.  In  the  upright  position  they  are  often  very 
faint.  They  are  usually  short  and  rarely  transmitted  beyond  the 
precordia  and  are  unaccompanied  by  any  evidences  of  enlargement 
of  the  heart,  by  any  pathological  accentuation  of  the  pulmonic  second 


VALVULAR  LESIONS  209 

sound, ^  or  any  evidences  of  engorgement  of  the  lungs  or  general  venous 
system. 

Cardiorespiratory  murmurs  are  usually  systolic,  and  as  they  are 
often  heard  in  and  about  the  mitral  area  they  are  frequently  mistaken 
for  evidence  of  a  mitral  leak.  From  this  they  should  be  distinguished 
by  their  variation  or  cessation  in  certain  phases  of  respiration  and 
by  the  absence  of  any  other  evidence  of  valvular  disease. 

(3)  Roughening  or  narrowing  of  the  aortic  valves  may  produce  a 
systolic  murmur  with  maximum  intensity  in  the  second  right  inter- 
costal space,  but  this  murmur  is  not  infrequently  heard  all  over  the 
precordia  and  very  plainly  at  the  apex,  so  that  it  may  simulate  the 
murmur  of  mitral  regurgitation.  The  aortic  murmur  may  indeed  be 
heard  more  plainly  at  the  apex  than  at  any  other  point  except  the 
second  right  intercostal  space,  owing  to  the  fact  that  the  right  ventricle, 
which  occupies  most  of  the  precordial  region  between  the  aortic  and 
mitral  areas,  does  not  lend  itself  well  to  the  propagation  of  certain 
types  of  cardiac  murmurs.  Under  these  circumstances  "  a  loud,  rough 
aortic  murmur  may  be  heard  at  the  apex  as  a  smooth  murmur  of  a 
different  tone"  (Broadbent).  Such  a  murmur  is  not,  however,  likely 
to  be  conducted  to  the  axilla  or  heard  beneath  the  left  scapula,  nor 
to  be  accompanied  by  accentuation  of  the  pulmonic  second  sound 
nor  evidences  of  engorgement  of  the  lungs  and  general  venous  system. 

(4)  Dilated  aorta  with  or  without  aneurism  may  produce  all  the 
signs  described  in  the  last  section.  The  evidences  of  such  dilatation 
are,  however,  obvious  in  most  cases  and  the  points  of  distinction  from 
mitral  disease  identical  with  those  mentioned  in  the  last  paragraph. 

II.  Mitral  Stenosis. 

Narrowing  or  obstruction  of  the  mitral  orifice  is  the  result  of  a 
chronic  endocarditis  which  gradually  glues  together  the  two  flaps  of 
the  valve  until  only  a  funnel-shaped  opening  or  a  slit  like  a  button- 
hole is  left  (see  Figs.  149  and  150).  As  we  examine  pOst-mortem  the 
tiny  slit  which  may  be  all  that  is  left  of  the  mitral  orifice  in  a  case  of 
long  standing,  it  is  difficult  to  conceive  how  sufficient  blood  to  carry  on 
the  needs  of  the  circulation  could  be  forced  through  such  an  insig- 
nificant opening. 

Usually   a   slow   and  gradually  developed  lesion,  mitral  stenosis 

^  It  must  be  remembered  that  in  chlorosis,  a  disease  in  which  functional  murmurs 
are  especially  prone  to  occur,  the  pulmonic  second  sound  is  often  surprisingly  loud,  omng 
to  a  retraction  of  the  left  lung,  which  uncovers  the  root  of  the  pulmonic  artery. 
14 


210 


PHYSICAL  DIAGNOSIS 


often  represents  the  later  stages  of  a  process  which  in  its  earlier 
phases  produced  pure  mitral  regurgitation.  By  some  observers  the 
advent  of  stenosis  is  regarded  as  representing  an  attempt  at  com- 


/^/f<^/^^/ 


Fig.  149. — Diagram  to  Represent  the  Position  of  the  Valves  in  the  Normal  Heart 
during  Diastole,  the  Open  Mitral  Allowing  the  Blood  to  Flow  from  the  Left  Auricle, 
the  Aortic  Closed. 


^%/ia/^a'J///ia/. 


Fig.  150. — Mitral  Stenosis — Period  of  Diastole.     The  blood  flowing  from  the  left  auricle 
is  obstructed  by  the  thickened  and  adherent  mitral  curtains. 


pensation  for  a  reduction  of  the  previous  mitral  leakage.  Others 
consider  that  the  stenosis  simply  increases  the  damage  which  the 
valve  has  suffered. 


VALVULAR  LESIONS 


211 


A  remarkable  fact  never  satisfactorily  explained  is  the  predilec- 
tion of  mitral  stenosis  for  the  female  sex.^  A  large  proportion  of  the 
cases — seventy-six  per  cent,  in  my  series — occur  in  women. 

Physical  Signs. 

Mitral  stenosis  may  exist  for  many  years  without  giving  rise  to 
any  physical  signs  by  which  it  may  be  recognized,  and  even  after 
signs  have  begun  to  show  themselves  they  are  more  fleeting  and  incon- 
stant than  in  any  other  valvular  lesion  of  the  heart.  In  the  early 
stages  of  the  disease  the  heart  may  appear  to  be  entirely  normal  if 
the  patient  is  at  rest,  and  especially  if  examined  in  the  recumbent 
position,  characteristic  signs  being  elicited  only  by  exertion;  or  again 
a  murmur  which  is  easily  audible  with  the  patient  in  the  upright 
position  may  disappear  in  the  recumbent  position;  or  a  murmur 
may  be  heard  at  one  visit,  at  the  next  it  may  be  impossible  to  elicit 


Pulmonic  second 
accented. 


'  Double-shock ' 
sound. 


Presystolic  murmur 
heard    in  limited 


Fig.   151. — Mitral  Stenosis. 


it  by  any  manoeuvre,  while  at  the  third  visit  it  may  be  easily  heard 
again.  These  characteristics  explain  to  a  certain  extent  the  fact 
that  differences  of  opinion  so  often  arise  regarding  the  diagnosis  of 
mitral  stenosis,  and  that  out  of  seventy-one  cases  in  which  this 
lesion  was  found  at  autopsy  at  the  Massachusetts  General  Hospital, 
only    forty-nine    were    recognized    during  life.     No   common  lesion 

^  Fenwick's  explanation,  viz.,  that  the  sedentar}'  life  of  women  favors  the  slow  adhesive 
inflammation  of  the  valve  and  its  curtains,  resulting  in  stenosis,  does  not  seem  to  me 
to  be  satisfactory. 


212  PHYSICAL  DIAGNOSIS 

(with    the    exception    of    tricuspid    regurgitation)   has  been  so  fre- 
quently overlooked  in  our  records. 

I  shall  follow  Broadbent  in  dividing  the  smyptoms  into  three 
stages,    according  to  the  extent  to  which  the  lesion  has  progressed. 

I. 

In  the  first  stage  inspection  and  palpation  show  that  the  apex 
beat  is  little  if  at  all  displaced,  and  percussion  reveals  no  increase 
in  the  area  of  cardiac  dulness;  there  is  often  local  tenderness  to  be 
elicited  near  the  apex.  If  one  lays  the  hand  lightly  over  the  origin 
of  the  apex  beat,  one  can  generally  feel  the  purring  presystolic  thrill 
which  is  so  characteristic  cf  this  disease.  This  thrill  is  more  marked 
in  the  second  stage  of  the  disease,  but  can  generally  be  appreciated 
even  in  the  first.  It  runs  up  to  and  ceases  abruptly  with  the  very 
sharp  first  sound,  the  sudden  shock  of  which  may  be  appreciated  even 


1st 


1st 


2n(I  .Hilllil  2nd 


1 


Fig.  152. — The  Murmur  of  Mitral  Stenosis — First  Stage.  The  place  of  the  murmur 
and  its  crescendo  character  indicated  by  the  position  of  the  light  lines  just  before  the  first 
sound  and  by  their  increasing  length. 

by  palpation.  The  thrill  is  sometimes  palpable  even  when  no  murmur 
can  be  heard,  and  often  the  thrill  is  transmitted  to  the  axilla  when  the 
murmur  is  confined  to  the  apex  region.  On  auscultation  one  hears, 
especially  after  the  patient  has  been  exerting  himself,  and  particularly 
if  he  leans  forward  and  to  the  left,  a  short  low-pitched  rumble  or  roll 
immedialely  preceding  the  systole  and  increasing  in  intensity  as  it 
approaches  the  first  sound.  At  this  stage  of  the  disease  the  second 
sound  can  still  be  heard  at  the  apex.  The  first  sound  is  very  sharply 
accented  on  snapping,  and  communicates  a  very  decided  shock  to  the 
ear  when  a  rigid  stethoscope  is  used.  As  a  rule,  the  murmur  is  closely 
confined  to  the  region  of  the  apex  beat  and  not  transmitted  any  con- 
siderable distance  in  any  direction.  I  have  seen  cases  in  which  it  was 
to  be  heard  only  over  an  area  the  size  of  a  half-dollar.^     Very  charac- 

'  It  may,  however,  be  widely  transmitted  to  the  left  axilla  and  audible  in  the  back  or 
even  over  the  whole  of  the  left  chest,  especially  when  the  stenosis  is  combined  with 
regurgitation. 


VALVULAR  LESIONS  213 

teristic  of  mitral  stenosis  is  a  prolongation  of  the  diastolic  pause  so 
that  the  interval  between  the  second  sound  of  one  cycle  and  the  first 
sound  of  the  next  is  unduly  long.  The  pulmonic  second  sound  is 
accented  and  often  loudly  reduplicated  ("double-shock  sound" — • 
Sansom)  at  this  stage  of  the  disease,  but  this  doubling  is  much  more 
frequent  later. "• 

Irregularity  of  the  heart  beat  both  in  force  and  rhythm  is  very 
frequently  present  even  in  the  early  stages  of  the  affection.  The 
heart  may  be  regular  while  the  patient  is  at  rest,  but  slight  exertion 
is  often  sufficient  to  produce  marked  irregularity. 

II. 

In  the  second  stage  the  murmur  and  thrill  are  usually  longer  and 
may  occupy  the  whole  of  diastole,  beginning  with  considerable  in- 
tensity just  after  the  reduplicated  second  sound,  quickly  diminishing 
until  barely  audible,  and  then  again  increasing  with  a  rapid  crescendo 
up    to    the  first  sound  of  the  next  cycle. ^     These  changes  may  be 

1st  1st 


I Ml     I       I       I       I       I      I      lllllllll 


Fig.  153. — Type  of  Presystolic  Murmur  Often  Heard  in  the  Second  Stage  of  Mitral 
Stenosis.  Here  the  murmur  fills  the  whole  of  diastole,  with  a  gradual  increase  of  intensity 
as  it  approaches  the  first  sound.     No  second  sound  is  audible  at  the  apex. 

graphically  represented  as  in  Figs.  152  and  153.  Diastole  and  the 
As-Vs  interval  of  the  phlebegram  (see  above,  p.  114)  are  now 
still  more  prolonged,  so  that  the  characteristic  rhythm  of  this  lesion 
is  even  more  marked  than  in  the  earlier  stages  of  the  disease.  In 
many  cases  at  this  stage  no  second  sound  is  to  be  heard  at  all  at  the 
apex,  although  at  the  pulmonic  orifice  it  is  loud  and  almost  invariably 
double.  (This  is  one  of  the  reasons  for  believing  that  the  second 
sound  which  we  usually  hear  at  the  apex  is  the  transmitted  aortic 

^  This  is  the  opinion  of  most  observers.  Sansom  has  stated  that  the  "double-shock 
sound"  may  precede  all  other  evidences  of  mitral  stenosis,  but  this  opinion  was  given 
before  the  discovery  by  Barie  and  Thayer  that  a  "third  heart  sound"  probably  identical 
with  one  of  the  beats  of  the  "double  shock  sound"  is  often  heard  in  healthy  young 
individuals. 

^  Rarely  one  finds  a  crescendo  in  the  middle  of  a  long  presystoUc  roll  with  a  diminuendo 
as  it  approaches  the  first  sound.     (See  Fig.  154.) 


214  PHYSICAL  DIAGNOSIS 

second  sound.  In  mitral  disease  the  aortic  valves  shut  feebly  owing 
to  the  relatively  small  amount  of  blood  that  is  thrown  into  the  aorta.) 

At  this  stage  of  the  disease  enlargement  of  the  heart  begins  to  make 
itself  manifest.  The  apex  impulse  is  displaced  to  the  left — sometimes 
as  far  as  the  mid- axillary  line,  and  often  descends  to  the  sixth  inter- 
space. Occasionally  the  cardiac  dulness  is  increased  to  the  right  of 
the  sternum  (right  auricle) . 

The  instability  and  fleeting  character  of  the  murmur  in  the  earlier 
stages  of  the  disease  are  much  less  marked  in  this,  the  second  stage. 


2n(l 

II.Mii  lilllllllllllllllllllllh  I  iNiil 


1st 


Srd 


Fig.  154. — Type  of  Presystolic  Murmur  Sometimes  Heard  in  the  Second  Stage  of  Mitral 
Stenosis.     There  is  a  double  crescendo.     The  second  sound  seems  reduplicated. 


The  first  sound  at  the  apex  still  retains  its  sharp,  thumping  quality,  and 
is  often  audible  without  the  murmur  in  the  back. 

The  irregularity  of  the  heart  is  generally  greater  at  this  stage 
than  in  the  earlier  one,  and  often  becomes  "absolute"  (auricular 
fibrillation) . 

III. 

The  third  stage  of  the  affection  is  marked  by  the  weakening  or  dis- 
appearance of  the  characteristic  murmur,  and  is  generally  synchronous 
with  the  development  of  tricuspid  regurgitation.  The  right  ventricle 
becomes  dilated  sometimes  very  markedly.  Indeed,  it  may  produce 
a  visible  pulsating  tumor  below  the  left  costal  border  and  be  mistaken 
for  cardiac  aneurism  (Osier).  The  snapping  first  sound  and  the 
"double-shock"  sound  usually  remain  audible,  but  the  latter  may  be 
absent  altogether.  Diagnosis  in  this  stage  rests  largely  upon  the 
peculiar  snapping  character  of  the  first  sound,  together  with  the 
prolongation  of  diastole  and  the  absolute  irregularity  of  the  heart,  both 
in  force  and  rhythm.  At  times  a  presystolic  thrill  may  be  felt  even 
when  no  murmur  is  to  be  heard. 

The  pulse  shows  nothing  characteristic  in  many  cases  except  that 
early  and  persistent  irregularity  which  has  been  already  alluded  to. 

As  the  disease  advances  the  irregularity  of  the  pulse  becomes  more 
and  more  marked,  and  sometimes  presents  an  amazing  contrast  with 


VALVULAR  LESIONS  215 

the  relatively  good  general  condition  of  the  circulation.  Even  when 
not  more  than  a  third  of  the  beats  reach  the  wrist,  the  patient  may  be 
able  to  attend  to  light  work  and  feel  very  well.  Such  cases  make  us 
feel  as  if  a  functionary  auricle  and  a  palpable  pulse  were  luxuries 
rather  than  necessities. 

Under  the  influence  of  digitalis  the  pulse  is  especially  apt  to  assume 
the  bigeminal  or  coupled  type  in  mitral  stenosis.  Every  other  beat  is 
then  so  abortive  that  it  fails  to  send  a  wave  to  the  wrist,  and  the  weak 
beat  is  succeeded  by  a  pause.     See  above,  p.  119. 

Mitral  stenosis  is  in  the  great  majority  of  cases  combined  with 
mitral  regurgitation,  and  it  often  happens  that  the  signs  of  regurgita- 
tion are  so  much  more  prominent  than  those  of  stenosis  that  the 
latter  escape  observation  altogether,  especially  in  the  third  stage  of 
the  disease,  when  the  typical  presystolic  roll  has  disappeared.  In 
such  cases  combined  stenosis  and  regurgitation  is  to  be  distinguished 
from  pure  regurgitation  by  the  sharpness  of  the  first  sound,  which 
would  be  very  unusual  at  this  stage  of  a  case  of  pure  mitral  regurgita- 
tion. The  presence  of  reduplicated  second  sound,  a  "double-shock 
sound  "  at  the  outset  of  the  prolonged  diastolic  pause,  and  the  absolute 
irregularity  of  the  pulse  are  further  suggestive  of  mitral  stenosis. 

Mitral  stenosis  is  apt  to  be  associated  with  haemoptysis,  with  en- 
gorgement of  the  liver  and  ascites,  and  especially  with  arterial  embo- 
lism. No  other  valve  lesion  is  so  frequently  found  associated  with  embo- 
lism. This  is  owing  to  the  very  frequent  formation  of  a  "ball"  or 
pedunculated  thrombus  in  the  left  auricular  appendage.  Sudden 
death  may  result  from  the  impaction  of  this  "ball"  in  the  funnel-like 
cone  of  the  stenosed  mitral  orifice.  More  often  bits  of  the  thrombus 
break  loose  and  are  "heard  from"  in  the  brain  (hemiplegia).  In  the 
spleen  and  kidneys  they  are  usually  "silent,  "  but  may  cause  sudden 
and  severe  pain. 

Differential  Diagnosis. 

I  have  already  discussed  the  difficulty  of  distinguishing  a  double 
lesion  at  the  mitral  valve  from  a  simple  mitral  regurgitation  (see 
above,  p.  205). 

Other  murmurs  which  may  be  mistaken  for  the  murmur  of  mitral 
stenosis  are: 

(a)   The  Austin  Flint  murmur. 

{b)  The  murmur  of  tricuspid  stenosis. 

(a)   The  Austin  Flint  murmur. 


216  PHYSICAL  DIAGNOSIS 

In  1862  Austin  Flint  studied  two  cases  in  which  during  life  a 
typical  presystolic  roll  was  audible  at  the  apex  of  the  heart,  yet  in 
which  post  mortem  the  mitral  valve  proved  to  be  perfectly' normal, 
and  the  only  lesion  present  was  aortic  insufficiency.  This  observation 
has  since  been  verified  by  Osier,  Bramwell,  Gairdner,  and  other  com- 
petent observers.  At  the  Massachusetts  General  Hospital  we  have 
had  many  such  cases  with  autopsy.  Yet,  despite  repeated  confirma- 
tion, Flint's  observation  has  remained  for  nearly  forty  years  unknown 
to  physicians  at  large.  Its  importance  is  this:  Given  a  case  of  aortic 
regurgitation — a  presystolic  murmur  at  the  apex  does  not  necessarily 
mean  stenosis  of  the  mitral  valve  even  though  the  murmur  has  the 
typical  rolling  quality  and  is  accompanied  by  a  palpable  thrill.  It  may 
be  only  one  of  the  by-effects  of  the  aortic  incompetency.  How  it  is 
that  a  presystolic  murmur  can  be  produced  at  the  apex  in  cases  of 
aortic  regurgitation  has  been  much  debated.  Some  beHeve  it  is  due 
to  the  impact  of  the  aortic  regurgitant  stream  upon  the  ventricular  side 
of  the  mitral  valve,  floating  it  out  from  the  wall  of  the  ventricle  so  as 
to  bring  it  into  contact  with  the  stream  of  blood  descending  from  the 
left  auricle.  Others  suppose  that  the  mingling  of  the  two  currents  of 
blood,  that  from  the  mitral  and  that  from  the  aortic  orifice,  is  sufficient 
to  produce  the  murmur. 

Between  the  "Austin  Flint  murmur"  thus  defined  and  the  mur- 
mur of  true  mitral  stenosis,  complicating  aortic  regurgitation,  diagno- 
sis may  be  impossible.  If  there  is  no  dilatation  of  the  mitral  orifice, 
and  no  regurgitation,  either  from  this  cause  or  from  deformities  of  the 
mitral  valve  itself,  any  evidence  of  engorgement  of  the  pulmonary 
circuit  (accentuation  of  the  pulmonic  second  sound,  oedema  of  the 
lungs,  haemoptysis,  and  cough)  speaks  in  favor  of  an  actual  narrowing 
of  the  mitral  valve,  while  the  absence  of  such  signs  and  the  presence 
of  a  predominating  hypertrophy  of  the  left  ventricle  tend  to  convince 
us  that  the  murmur  is  of  the  type  described  by  Austin  Flint,  i.e.,  that 
it  does  not  point  to  any  stenosis  of  the  mitral  valve.  The  sharp,  snap- 
ping first  sound,  the  thrill  and  systolic  shock  so  characteristic  of 
mitral  stenosis  are  said  to  be  modified  or  absent  in  connection  with 
murmurs  of  the  Austin  Flint  type. 

(6)   Tricuspid  obstruction. 

Luckily  for  us  as  diagnosticians,  stenosis  of  the  tricuspid  valve  is  a 
very  rare  lesion.  Like  mitral  stenosis  it  is  manifested  by  a  presystolic 
rolling  murmur  whose  point  of  maximum  intensity  is  sometimes  over 
the  traditional  tricuspid  area,  but  may  be  at  a  point  so  near  the  mitral 
area  as  to  be  easily  confused  with  stenosis  of  the  latter  valve. 


VALVULAR  LESIONS  217 

The  difficulty  of  distinguishing  tricuspid  stenosis  from  mitral 
stenosis  is  further  increased  by  the  fact  that  the  two  lesions  almost 
invariably  occur  in  conjunction.  Hence  we  have  two  presystolic 
murmurs,  perhaps  with  slightly  different  points  of  maximum  intensity 
and  possibly  with  a  difference  in  quality,  but  often  quite  undistinguish- 
able  from  each  other.  In  the  vast  majority  of  cases,  therefore,  tri- 
cuspid stenosis  is  first  recognized  at  the  autopsy,  and  the  diagnosis 
is  at  best  a  very  difficult  one.  When  a  mitral  stenosis  seems  to 
yield  to  treatment  much  less  readily  and  satisfactorily  than  we  should 
suspect,  considering  the  age  and  general  condition  of  the  patient,  we 
may  guess  that  a  tricuspid  obstruction  (perhaps  also  an  aortic 
stenosis)  is  present  as  well. 

(c)  Broadbent,  Rosenbach,  and  others  have  noticed  in  children 
who  have  just  passed  through  an  attack  of  pericarditis  a  rumbling 
murmur  near  the  apex  of  the  heart,  which  suggests  the  murmur  of 
mitral  stenosis.  It  is  distinguished  from  the  latter,  however,  by  the 
absence  of  any  accentuation  of  the  first  sound  at  the  apex,  as  well  as 
by  the  conditions  of  its  occurrence  and  by  its  transiency.  Such  cases 
are  important,  since  their  prognosis  is  much  more  favorable  than  that 
of  mitral  stenosis. 

Phear  (Lancet,  September  21,  1895)  investigated  46  cases  irt  which 
a  presystolic  murmur  was  observed  during  life  and  no  mitral  lesion 
found  at  autopsy.  In  17  of  these  there  was  aortic  regurgitation  at 
autopsy;  in  20  of  these  there  was  adherent  pericardium  at  autopsy; 
in  9  nothing  more  than  dilatation  of  the  left  ventricle  was  found.  In  none 
of  these  cases  was  the  snapping  first  sound,  so  common  in'  mitral 
stenosis,  recorded  during  life.  This  finding  of  presystolic  murmurs  in 
various  conditions  involving  left  ventricular  hypertrophy  (nephritis, 
arteriosclerosis)  is  entirely  in  accord  with  my  own  experience  and 
tends  to  show  that  the  Austin  Flint  murmur  is  due  to  the  enlarged 
left  ventricle  characteristic  of  aortic  regurgitation  and  not  to  the 
regurgitation  itself. 

All  this  resolves  itself  for  me  into  the  belief  that  when  the  heart  is 
much  enlarged  nothing  that  you  hear  at  the  end  is  of  much  importance 
as  evidence  of  valvular  disease,  except  the  rare  axillary  diastolic 
murmur  of  aortic  regurgitation.  Systolic  and  presystolic  murmurs  at 
the  apex  of  a  very  large  heart  have  little  significance. 

It  should  be  remembered  that  patients  suffering  from  mitral 
stenosis  are  very  frequently  unaware  of  any  cardiac  trouble,  and  seek 
advice  for  anaemia,  wasting,  debility,  gastric  or  pulmonary  complaints. 
This  is  less  often  true  in  other  forms  of  valvular  disease.     We  should 


218  PHYSICAL  DIAGNOSIS 

be  especially  on  our  guard  in  cases  of  supposed  "nervous  arrhythmia" 
or  "tobacco  heart,"  if  there  has  been  an  attack  of  rheumatism  or 
chorea  previously.  Such  cases  may  present  no  signs  of  disease  except 
the  irregularity — ^yet  may  turn  out  to  be  mitral  stenosis. 

IV.  Aortic  Regurgitation. 

Rheumatic  endocarditis  usually  occurs  in  early  life  and  most  often 
attacks  the  mitral  valve.  The  commonest  cause  of  aortic  disease  on 
the  other  hand — syphilitic  aortitis — occurs  at  all  ages  and  attacks 
men  much  more  often  than  women.  Nevertheless  cases  occur  at  all 
ages  and  in  both  sexes,  and  rheumatic  endocarditis  does  not  spare  the 
aortic  cusps  altogether  by  any  means. 


T.Afitta/  ^ff^r/ej. 


Fig.   155. — Diastole  in  Aortic  Regurgitation.     The  blood  is  flowing  back  through  the 
stumpy  and  incompetent  aortic  valves. 

Whether  produced  by  syphilitic  aortitis  extending  down  from  the 
aorta,  or  by  rheumatic  or  septic  endocarditis,  the  lesion  which  results 
in  aortic  regurgitation  is  usually  a  thickening  and  shortening  of  the 
cusps  (see  Fig.  155).  In  rare  cases  it  is  said  that  an  aortic  cusp  may 
be  ruptured  as  a  result  of  violent  muscular  effort,  and  the  signs  and 
symptoms  of  regurgitation  may  then  appear  suddenly.  I  have  never 
seen  such  a  case ;  as  a  rule  the  lesion  comes  on  slowly  and  insidiously, 
and  unless  discovered  accidentally  or  in  the  course  of  routine  physical 
examination  it  may  exist  unnoticed  for  years.  Dropsy  and  cyanosis 
are  relatively  late  and  rare,  and  the  symptoms  which  first  appear  are 
usually  those  of  dyspnoea  and  precordial  distress. 

It  is  a  disputed  point  whether  relative  and  temporary  aortic  in- 
sufficiency due  to  stretching  of  the  aortic  orifice  ever  occurs.     If  it 


VALVULAR  LESIONS  219 

does  occur,  it  is  certainly  exceedingly  rare,  as  the  aortic  ring  is  very 
tough  and  inelastic. 

Dilatation  of  the  aortic  arch — ^resembling  diffuse  aneurism — occurs 
in  almost  every  case  of  aortitis  and  aortic  regurgitation,  and  produces 
several  important  physical  signs.  This  complication  is  a  very  well- 
known  one,  but  has  not,  I  think,  been  sufficiently  insisted  on  in  text- 
books of  physical  diagnosis.  It  forms  part  of  that  general  enlarge- 
ment of  the  arterial  tree  which  is  so  characteristic  of  the  disease. 

Physical  Signs. 

Inspection  reveals  more  that  is  important  in  this  disease  than  in 
any  other  valvular  lesion.  In  extreme  cases  the  patient's  face  or 
hand  may  blush  visibly  with  every  systole.  Not  infrequently  one  can 
make  the  diagnosis  across  the  room  or  in  the  street  by  noting  the 
violent  throbbing  of  the  carotids,  which  may  be  such  as  to  shake  the 
person's  whole  head  and  trunk,  and  even  the  bed  on  which  he  lies. 
No  other  lesion  is  so  apt  to  cause  a  heaving  of  the  whole  chest  and  a 
bobbing  of  the  head,  and  no  other  lesion  so  often  causes  a  bulging  of 
the  precordia,  for  in  no  other  lesion  is  the  enlargement  of  the  heart  so 
great  {cor  bovinum  or  ox-heart).  The  throbbing  of  the  dilated  aorta 
can  often  be  felt  and  sometimes  seen  in  the  suprasternal  notch  or  in 
the  second  right  interspace.  Not  only  the  carotids  but  the  sub- 
clavians,  the  brachials  and  radials,  the  femoral  and  anterior  tibial,  and 
even  the  digital  and  dorsalis  pedis  arteries  may  visibly  pulsate,  and 
the  characteristic  jerking  quality  of  the  pulse  may  be  seen  as  well  as 
felt.  This  visible  pulsation  in  the  peripheral  arteries,  while  very 
characteristic  of  aortic  regurgitation,  is  occasionally  seen  in  cases  of 
simple  hypertrophy  of  the  heart  from  hard  muscular  work  {e.g.,  in 
athletes)  as  well  as  in  arteriosclerosis,  Graves'  disease,  and  in  severe 
anaemias.  If  the  arteries  are  extensively  calcified,  their  pulsation  may 
become  much  less  marked. 

The  peculiar  conditions  of  the  circulation  whereby  it  is  "changed 
into  a  series  of  discontinuous  discharges  as  if  from  a  catapult"  (All- 
butt)  throws  a  great  tensile  strain  upon  all  the  arteries,  and  results,  in 
almost  every  long-standing  case,  in  increasing  both  their  length  and 
their  diameter.  The  visible  arterial  trunks  become  tortuous  and 
distended,  while  the  arch  of  the  aorta  is  diffusely  dilated  so  as  to 
resemble  an  aneurism  (see  Fig.  156).  With  each  heart  beat  the 
snaky  arteries  are  often  jerked  to  one  side  as  well  as  made  to  throb. 

Inspection  of  the  region  of  the  cardiac  impulse  almost  always 


220  PHYSICAL  DIAGNOSIS 

shows  a  very  marked  displacement  of  the  apex  beat  both  downward 
and  outward  (but  especially  the  former) ,  corresponding  to  the  hyper- 
trophy and  still  more  to  the  dilatation  of  the  left  ventricle,  which  is 
usually  very  great,  and  to  the  downward  sagging  of  the  enlarged  aorta. 
Dilatation  is  in  this  disease  an  essentially  helpful  and  compensatory 
process.  Not  at  all  infrequently  one  finds  a  systolic  retraction  of  the 
interspaces  near  the  apex  beat  instead  of  a  systolic  impulse.  This  is 
probably  due  to  the  negative  pressure  produced  within  the  chest  by 

Pulsation  at  the  jugulum. 
/ 
I  /\  _,^'    Pulsating  carotids. 


^^^'A\~_,_---^      •— Sfc-    .     Y  il ^"       1 —    Diastolic  murmur. 

Dulness  and  pul-        J,--'  j    /v^     ^y^Cr^    j^^\/\©aA    \  ' 

sation       corre-    -'"  /\   1  V'^^^^ZiC^<^vAS^^  r^^^^^ri   /\ 

spending  to  the                           \  ^>v-^<iV   ^/V%!J:^^^  -     Displaced  cardiac 

dilated      aortic  VR^^  V^^I impulse. 


Fig.  156. — Aortic  Regurgitation,  Showing  Position  of  the  DiastoUc  Murmur  and  Areas 

of  Visible  Pulsation. 

the  powerful  contraction  of  an  hypertrophied  heart.  In  the  supra- 
sternal notch  one  often  feels  as  well  as  sees  a  marked  systolic  pulsation 
transmitted  from  the  arch  of  the  dilated  aorta,  and  sometimes  mis- 
taken for  saccular  aneurism. 

Capillary  Pulsation. 

If  one  passes  the  end  of  a  pencil  or  other  hard  substance  once  or 
twice  across  the  patient's  forehead,  and  then  watches  the  red  mark 
so  produced,  one  can  often  see  a  systolic  flushing  of  the  hyperaemic 
area  with  each  beat  of  the  heart.  This  is  by  far  the  best  method  of 
eliciting  this  phenomenon.  It  may  also  be  seen  if  a  glass  slide  is 
pressed  against  the  mucous  membrane  of  the  lip  so  as  partially  to 
blanch  it,  or  if  one  presses  upon  the  finger-nail  so  as  partially  to  drive  the 
blood  from  under  it ;  but  in  both  these  manoeuvres  error  may  result  from 


VALVULAR  LESIONS  221 

inequality  in  the  pressure  made  by  the  observer  upon  the  glass  slide 
or  upon  the  nail.  Very  slight  movements  of  the  observer's  fingers, 
even  such  as  are  caused  by  his  own  pulse,  may  give  rise  to  changes 
simulating  capillary  pulsation.  Capillary  pulsation  of  normal  tissues 
is  not  often  seen  in  any  condition  other  than  aortic^  regurgitation, 
yet  occasionally  one  meets  with  it  in  diseases  which  produce  very  low 
tension  of  the  pulse,  such  as  Graves'  Disease,  phthisis  or  typhoid, 
anaemic  and  neurasthenic  conditions,  and  I  have  twice  seen  it  in  per- 
fectly healthy  persons.  In  such  cases  the  pulsation  is  usually  less 
marked  than  in  aortic  regurgitation. 

Palpation. 

Palpation  verifies  the  position  of  the  cardiac  impulse  and  the  heav- 
ing of  the  whole  chest  wall  suggested  by  inspection.  The  shock  of 
the  heart  is  very  powerful  and  deliberate  unless  dilatation  is  extreme, 
when  it  becomes  wavy  and  diffuse.  In  the  supraclavicular  notch  a 
systolic  thrill  is  often  to  be  felt.  A  diastolic  thrill  in  the  precordia  is 
very  rare. 


Fig.  157. — Sphygmographic  Tracing  from  Normal  Pulse. 

The  pulse  is  important,  usually  characteristic.  The  wave  rises  very 
suddenly  and  to  an  unusual  height,  then  collapses  completely  and  with 
great  rapidity  (pulsus  celer)   (see  Figs.  157,  158). 

This  type  of  pulse,  which  is  known  as  the  "Corrigan  pulse"  or  "water- 
hammer  pulse,"  is  exaggerated  if  one  raises  the  patient's  arm  above 
the  head  so  as  to  make  the  force  of  gravity  aid  in  emptying  the  artery. 
The  quality  of  the  pulse  in  aortic  regurgitation  is  due  to  the  fact  that 
a  large  volume  of  blood  is  suddenly  and  forcibly  thrown  into  the  aorta 
by  the  hypertrophied  and  dilated  left  ventricle,  thus  causing  the 
characteristically  sharp  and  sudden  rise  in  the  peripheral  arteries. 
The  arteries  then  empty  themselves  in  two  directions  at  once,  forward 

^  Jumping  toothache  and  throbbing  felon  are  common  examples  of  capillary  pulsation 
in  inflammed  area. 


222  PHYSICAL  DIAGNOSIS 

into  the  capillaries  and  backward  into  the  heart  through  the  incom- 
petent aortic  valves;  hence  the  sudden  collapse  in  the  pulse  which, 
together  with  its  sharp  and  sudden  rise,  are  its  important  character- 
istics. The  arteries  are  large  and  often  elongated  so  as  to  be  thrown 
into  curves. 


Fig.  158. — Sphygmographic  Tracing  of  the  " Pulsus  Celer"  in  Aortic  Regurgitation.     Its 
collapsing  character  is  well  shown. 

While  compensation  lasts,  the  pulse  is  usually  regular  in  force 
and  rhythm.  Irregularity  is  therefore  an  especially  grave  sign,  much 
more  so  than  in  any  other  valvular  lesion. 

Percussion. 

Percussion  adds  but  little  to  the  information  obtained  by  inspec- 
tion and  palpation,  but  verifies  the  results  of  these  methods  of  investi- 
gation respecting  the  increased  size  of  the  heart,  and  especially  of  the 
left  ventricle,  which  may  reach  enormous  dimensions,  especially]  in 
cases  occurring  in  young  persons.  The  heart  may  be  increased  to 
more  than  four  times  its  normal  weight. 

Auscultation. 

In  rare  cases  there  may  be  absolutely  no  murmur  and  the  diag- 
nosis may  be  impossible  during  life,  though  it  may  be  suspected  by 
reason  of  the  above-mentioned  signs  in  the  peripheral  arteries.  Un- 
less the  free  ear  is  used  the  murmur  is  often  so  faint  as  to  be  easily 
overlooked.  This  is  especially  true  in  cases  occurring  in  elderly 
people,  and  when  the  patient  has  been  for  a  considerable  time  at  rest. 
The  difficulty  of  recognizing  certain  cases  of  aortic  regurgitation 
during  life  is  shown  by  the  fact  that  out  of  sixty-eight  cases  of  aortic 
regurgitation  demonstrated  at  aiitopsy  in  the  Massachusetts  General 
Hospital,  only  fifty-seven  or  84%  were  recognized  during  life. 


VALVULAR  LESIONS 


223 


In  the  majority  of  cases,  however,  the  characteristic  diastolic 
murmur  is  easily  heard  if  one  listens  in  the  right  place,  and  when 
heard  it  is  the  most  distinctive  and  trustworthy  of  all  cardiac  murmurs. 
It  almost  invariably  points  to  aortic  regurgitation  and  to  nothing  else. 

The  murmur  of  aortic  regurgitation,  as  has  been  already  men- 
tioned, is  diastolic  in  time.'-  Its  maximum  intensity  is  usually  not 
in   the  conventional   aortic   area    {second  right  interspace),   but   on  the 


Fig.  159. — Position  of  the  Point  of  Maximum  Intensity  of  the!  Murmur  of  Aortic 
Regurgitation.  The  dots  are  most  thickly  congregated  where  the,  murmur  is  oftenest 
heard. 


left  side  of  the  sternum  about  the  level  of  the  fourth  left  costal  cartilage. 
In  about  one-fifth  of  the  cases,  and  especially  when  the  aortic  arch 
is  much  dilated,  the  murmur  is  best  heard  in  the  conventional  aortic 
area.  Occasionally  there  are  two  points  at  which  it  may  be  loudly 
heard — one  in  the  second  right  interspace  and  the  other  at  or  outside 
the  cardiac  apex,  while  between  these  points  the  murmur  is  faint. 
This  is  probably  due  to  the  fact  that  the  left  ventricle,  through  which 
the  murmur  is  conducted,  approaches  the  surface  of  the  chest  only  at 
the  apex,  while  the  intermediate  space  is  occupied  by  the  right  ventri- 
cle, which  often  fails  readily  to  transmit  murmurs  produced  at  the 
aortic  orifice.  Less  frequently  the  murmur  of  aortic  regurgitation  is 
heard  with  maximum  intensity  at  the  second  or  third  left  costal  carti- 

^  Another  murmur,  systoUc  in  time,  which  almost  always  accompanies  the  diastolic 
murmur,  is  usually  due  to  roughening  of  the  edges  of  the  aortic  valves  or  to  dilatation  of 
the  aortic  arch.  This  murmur  must  not  be  assumed  to  mean  aortic  stenosis  (see  below, 
p.  230). 


224  PHYSICAL  DIAGNOSIS 

lage  at  the  apex,  in  the  left  axilla,  or  in  the  region  of  the  ensiform  car- 
tilage (see  Fig.  159). 

From  its  seat  of  maximum  intensity  {i.e.,  usually  from  the  fourth 
left  costal  cartilage)  the  murmur  is  transmitted  in  all  directions,  but 
not  often  beyond  the  precordia.  In  about  one-third  of  the  cases  it  is 
transmitted  to  the  left  axilla  or  even  to  the  back.  It  is  sometimes  to 
be  heard  in  the  subclavian  artery  and  the  great  vessels  of  the  neck; 
in  other  cases  two  heart  sounds  are  audible  in  the  carotid,  but  no  mur- 
mur. The  murmur  is  usually  blowing  and  relatively  high  pitched, 
sometimes  musical.  Its  intensity  varies  much,  but  is  most  marked  at 
the  beginning  of  the  murmur,  giving  the  impression  of  an  accent  there. 
It  may  occupy  the  whole  of  diastole  or  only  a  small  portion  of  it — 
usually  the  earlier  portion  (see  Fig.  160).     Late  diastolic  murmurs  are 


1st  1st 

I  2ud  I 


2iid 


Fig.  160. — Short  Diastolic  Murmur  Not  Replacing  the  Second  Sound. 

rare.  The  murmur  may  or  may  not  replace  the  second  sound  of  the 
heart.  Broadbent  believes  that  when  it  does  not  obliterate  the 
second  sound,  the  lesion  is  usually  less  severe  than  when  only  the 
murmur  is  to  be  heard.     Allbutt  dissents  from  this  opinion. 

The  position  of  the  patient's  body  has  but  little  effect  upon  the 
murmur — ^less  than  upon  murmurs  produced  at  the  mitral  orifice. 

The  first  sound  at  the  apex  is  generally  dull  and  long.  There  is  no 
accentuation  of  the  pulmonic  second. 

Over  the  larger  peripheral  arteries,  especially  over  the  femoral 
artery,  one  hears  in  most  cases  a  sharp,  short  systolic  sound  ("pis- 
tol-shot sound")  due  to  the  sudden  filling  of  the  unusually  empty 
artery;  this  sound  is  merely  an  exaggeration  of  what  may  be  heard 
in  health.  Pressure  with  the  stethoscope  will  usually  bring  out  a 
systolic  murmur  (as  also  in  health),  and  occasionally  a  diastolic  mur- 
mur as  well  (Duroziez's  sign) .  This  diastolic  murmur  in  the  peripheral 
arteries,  obtained  on  pressure  with  the  stethoscope,  is  practically 
never  heard  except  in  aortic  regurgitation.  It  is  thought  by  some 
to  be  due  to  the  regurgitant  current  in  the  great  vessels  which  in  very 
marked  cases  may  extend  as  far  as  the  femoral  artery.  Duroziez's 
sign  is  a  comparatively  rare  one,  not  present  in  most  cases  of  aortic 
regurgitation,  and  usually  disappears  when  compensation  fails. 


VALVULAR  LESIONS  225 

Summary  and  Differential  Diagnosis. 

A  diastolic  murmur  heard  with  the  maximum  intensity  about  the 
fourth  left  costal  cartilage  (less  often  in  the  second  right  interspace) 
gives  us  almost  complete  assurance  of  the  existence  of  aortic  regurgita- 
tion. From  mitral  stenosis  and  from  pulmonary  regurgitation,  an 
exceedingly  rare  lesion,  the  disease  is  distinguished  by  the  presence  of 
predominating  hypertrophy  of  the  left  ventricle  with  a  heaving  apex 
impulse  and  by  the  following  arterial  phenomena: 

(a)  Visible  pulsation  in  the  peripheral  arteries. 

(b)  Capillary  pulsation. 

(c)  "Corrigan"  pulse. 

(d)  "Pistol-shot  sound"  in  the  femoral  artery. 

(e)  Duroziez's  sign. 

(/)   High  pulse-pressure  (see  above,  p.  iii). 

Cardiopulmonary  murmurs  (see  page  i88)  are  occasionally  dias- 
tolic, but  are  very  markedly  influenced  by  position  and  by  respiration, 
while  aortic  murmurs, 'are  but  slightly  modified. 

The  very  rare  functional  diastolic  murmur,  transmitted  from  the 
veins  of  the  neck  and  heard  over  the  base  of  the  heart  in  cases  of 
grave  anaemia,  may  be  obliterated  by  pressure  over  the  bulbus  jugu- 
laris.  Such  pressure  has  no  effect  upon  the  murmur  of  arotic  regur- 
gitation. I  have  recently  reported  (Johns  Hopkins  Bull.,  May, 
1903)  three  cases  of  intense  anaemia  associated  with  diastolic  mur- 
murs exactly  like  those  of  aortic  regurgitation,  but  proved  post  mortem 
to  be  independent  of  any  valvular  lesion.  The  arterial  phenomena 
were  not  marked,  but  the  diagnosis  of  such  cases  is  very  hard.  Luck- 
ily they  are  rare.  The  origin  is  obscure.  It  must  be  remembered 
that  aortic  regurgitant  murmurs  are  often  exceedingly  faint,  and 
should  be  listened  for  with  the  greatest  care  and  under  the  most  favor- 
able conditions. 

Estimation  of  the  Extent  and  Gravity  of  the  Lesion.  . 

The  extent  of  the  lesion  is  roughly  proportional  to — 

(a)  The  amount  of  hypertrophy  of  the  left  ventricle. 

(b)  The  degree  to  w;hich  the  pulse  collapses  during  diastole 
(provided  the  radial  is  not  'so  much  calcified  as  to  make  collapse 
impossible) . 

(c)  The  degree  to  which  the  murmur  replaces  the  second  sound 
as  heard  over  the  right  carotid  artery  (Broadbent). 

15 


226  PHYSICAL  DIAGNOSIS 

Irregularity  of  the  pulse  is  a  far  more  serious  sign  in  this  disease 
than  in  lesions  of  the  mitral  valve,  and  indicates  the  beginning  of  a 
serious  failure  of  compensation. 

Another  grave  sign  is  a  diminution  in  the  intensity  of  the  murmur. 

Complications. 

(i)  Dilatation  of  the  Aorta. — Diffuse  dilatation  of  the  aortic  arch 
is  usually  associated  with  aortic  regurgitation  and  may  produce  a 
characteristic  area  of  dulness  to  the  right  of  the  sternum  (see  Fig. 
156).  Not  infrequently  this  dilatation  is  the  cause  of  a  systolic  mur- 
mur to  be  heard  over  the  region  of  the  aortic  arch  and  in  the  great 
vessels  of  the  neck. 

(2)  Roughening  of  the  Aortic  Valves. — In  almost  all  cases  of  aortic 
regurgitation  the  valves  are  sufficiently  roughened  to  produce  a  systolic 
murmur  as  the  blood  flows  over  them.  This  murmur  is  heard  at  or 
near  the  conventional  aortic  area,  and  may  be  transmitted  into  the 
carotids.  (The  relation  of  these  murmurs  to  the  diagnosis  of  aortic 
stenosis  will  be  considered  with  the  latter  lesion.) 

(3)  The  return  of  arterial  blood  through  the  aortic  valves  into  the 
left  ventricle  produces  in  time  both  hypertrophy  and  dilatation  of  this 
chamber,  and  results  ultimately  in  a  stretching  of  the  mitral  orifice 
which  renders  the  mitral  curtains  incompetent.  The  result  is  a 
"relative  mitral  insufficiency,"  i.e.,  one  in  which  the  mitral  valve  is 
intact  but  too  short  to  reach  across  the  orifice  which  it  is  intended  to 
close.  Such  an  insufficiency  of  the  mitral  occurs  in  most  well-marked 
cases;  it  temporarily  relieves  the  overdistention  of  the  left  ventricle 
and  often  the  accompanying  angina,  although  at  the  cost  of  engorging 
the  lungs.  ^ 

(4)  The  Austin  Flint  Murmur. — -The  majority  of  cases  of  aortic 
regurgitation  are  accompanied  by  a  presystolic  murmur  at  the  apex. 
(For  a  fuller  discussion  of  this  murmur  see  above,  p.  215.) 

(5)  Aortic  stenosis  frequently  accompanies  cases  of  aortic  regurgi- 
tation, especially  in  the  rheumatic,  choreic  and  tonsillar  types  occurring 
in  young  persons.  It  has  the  effect  of  increasing  the  intensity  of  the 
diastolic  murmur,  since  the  regurgitating  stream  has  to  pass  through 
a  smaller  opening. 

The  excessive  arterial  pulsation  may  be  less  marked  if  stenosis 
accompanies  regurgitation,  but  this  is  not  always  the  case  (see  below, 
p.  230). 

^  This  relative  insufficiency  of  the  mitral  valve  has  been  termed  its  "safety-valve" 
action,  but  the  safety  is  but  temporary  and  dearly  bought. 


VALVULAR  LESIONS 


227 


Aortic  Stenosis. 

Uncomplicated  aortic  stenosis  is  by  far  the  rarest  of  the  valvular 
lesions  of  the  left  side  of  the  heart,  as  well  as  the  most  difficult  to  recog- 
nize. Out  of  two  hundred  and  fifty-two  autopsies  made  at  the  Massa- 
chusetts General  Hospital  in  cases  of  valvular  disease  there  was  not  one 
of  uncomplicated  aortic  stenosis .  Thirty  cases  occurred  in  combination 
with  aortic  regurgitation.  Of  these  19  or  63  %  were  recognized  in  life 
and  II  or  36%  were  not  recognized.  During  life  the  diagnosis  of 
aortic  stenosis  is  frequently  made,  but  often  on  insufficient  evidence — 
i.e.,  upon  the  evidence  of  a  systolic  murmur  heard  with  maximum 
intensity  in  the  second  right  intercostal  space  and  transmitted  into  the 
vessels  of  the  neck.     Such  a  murmur  does  indeed  occur  in  aortic 


'/c/^j/k/, . 


Fig.  161. — Aortic  Stenosis.     The  heart  is  in  systole  and  the  blood  column  is  obstructed 
by  the  narrowed  aortic  ring.     The  mitral  is  closed  (as  it  should  be). 


stenosis,  but  is  by  no  means  peculiar  to  this  condition.     Of  the  other 

diseases  which  produce  a  similar  murmur  more  will  be  said  under 

Differential  Diagnosis. 

For  the  diagnosis  of  aortic  stenosis  we  need  the  following  evidence : 
(i)   A  systolic  murmur  heard  best  in  the  second  right  intercostal 

space  and  transmitted  to  the  neck. 

(2)  The  characteristic  pulse  {vide  infra) . 

(3)  A  palpable  thrill  (usually) . 

(4)  Absence  or  great  enfeeblement  of  the  aortic  second  sound.  ^ 

'  Against  all  reason  I  have  twice  seen  at  autopsy  an  aortic  stenosis  despite  the  fact 
that  the  "  aortic  second  sound"  had  been  loud  in  life. 


228  PHYSICAL  DIAGNOSIS 

Of  these  signs  the  characteristic  pulse  is  the  most  important.  The 
heart  may  or  may  not  be  enlarged. 

Each  of  these  points  will  now  be  described  more  in  detail. 

(i)    The  Murmur. 

(a)  The  maximum  intensity  of  the  murmur,  as  has  already  been 
said,  is  usually  in  the  second  right  intercostal  space  near  the  sternum 
or  a  little  above  that  point  near  the  sterno-clavicular  articulation,  but 
it  is  by  no  means  uncommon  to  find  it  lower  down,  i.e.,  in  the  third, 
fourth,  or  fifth  right  interspace,  and  occasionally  it  is  best  heard  to  the 
left  of  the  sternum  in  the  second  or  third  intercostal  space.  (6)  The 
time  of  the  murmur  is  late  systolic;  that  is,  it  follows  the  apex  impulse 
at  an  appreciable  interval,  contrasting  in  this  respect  with  the  systolic 


Maximum  intensity      _[__ 
of    systolic    mur- 
mur and  thrill. 


Fig.  162. — Aortic  Stenosis.     The  murmur  is  audible  over  the  shaded  area  and  sometimes 

over  the  whole  chest. 

murmur  usually  to  be  heard  in  mitral  regurgitation,  (c)  The  mur- 
mur is  usually  -widely  transmitted,  often  being  audible  over  the  whole 
chest  and  occasionally  over  the  skull  and  the  arterial  trunks  of  the 
extremities  (see  Fig.  162).  It  is  usually  heard  less  well  over  that  por- 
tion of  the  precordia  occupied  by  the  right  ventricle,  while,  on  the 
other  hand,  it  is  relatively  loud  in  the  region  of  the  apex  impulse, 
whither  it  is  transmitted  through  the  left  ventricle.  The  same  line  of 
transmission  was  mentioned  above  as  characteristic  of  the  murmur  of 
aortic  regurgitation  in  many  cases.  The  murmur  is  also  to  be  heard 
■over  the  carotids  and  subclavians,  and  can  often  be  traced  over  the 
thoracic  aorta  along  the  spine  and  down  the  arms. 


VALVULAR  LESIONS  229 

Until  compensation  fails  the  murmur  is  apt  to  be  a  very  loud  one, 
especially  in  the  recumbent  position ;  it  is  occasionally  audible  at  some 
distance  from  the  chest,  and  is  often  rough  and  vibrating,  sometimes 
musical  or  croaking.  Its  length  is  unusually  great,  extending  through- 
out the  whole  of  systole,  but  to  this  rule  there  are  occasional  exceptions. 
The  first  sound  in  the  aortic  region  is  altogether  obliterated,  as  a  rule, 
and  the  second  sound  is  usually  either  absent  or  very  feeble.^ 

(2)    The  Pulse. 

Owing  to  the  opposition  encountered  by  the  left  ventricle  in  its 
attempt  to  force  blood  into  the  aorta,  its  contraction  is  apt  to  be 
prolonged;  hence  the  pulse  wave  rises  gradually  and  late,  and  falls 
away  slowly.  This  is  shown  very  well  in  sphygmographic  tracings 
(see  Fig.  163).  But  further,  the  blood  thrown  into  the  aorta  by  the 
left  ventricle  is  prevented,  by  the  narrowing  of  the  aortic  valves,  from 
striking  upon   and  expanding  the  arteries  with  its   ordinary  force; 


Fig.  163. — Sphygmographic  Tracing  of  the  Pulse  in  UncompUcated  Aortic  Stenosis. 
Compare  with  the  normal  pulse  wave  and  with  that  of  aortic  regurgitation  (pages  221  and 
222). 

hence  the  pulse  wave  is  not  only  slow  to  rise  but  small  in  height,  con- 
trasting strongly  with  the  powerful  apex  beat  {''pulsus  parvus'''). 
Again,  the  delay  in  the, emptying  of  the  left  ventricle,  brought  about 
by  the  obstruction  at  the  aortic  valves,  renders  the  contractions  of  the 
heart  relatively  infrequent,  and  hence  the  pulse  is  infrequent  {pulsus 
rarus)  as  well  as  small  and  slow  to  rise.  The  ''pulsus  rarus,  parvus, 
tardus"  is,  therefore,  a  most  constant  and  important  point  in  diagnosis, 
but  unfortunately  it  is  to  be  felt  in  perfection  only  in  the  very  rare 
cases  in  which  aortic  stenosis  occurs  uncomplicated.  When  stenosis 
is  combined  with  regurgitation,  as  is  almost  always  the  case,  the 
above-described  qualities  of  the  pulse  are  usually  modified  as  a  result 
of  the  regurgitation.  But  I  have  in  two  cases  observed  a  well  marked 
'  "  Occasionally,  as  noted  by  W.  H.  Dickinson,  there  is  a  muscial  murmur  of  great 
intensity  in  the  region  of  the  apex,  probably  due  to  a  slight  regurgitation  at  high  pressure 
through  the  mitral  valve." — Osler. 


230  PHYSICAL  DIAGNOSIS 

"Corrigan"   pulse  in  life  and  been  confronted  post  mortem  with  a 
narrowed,  rigid  aortic  valve! 

The  slow,  long  pulse  with  a  long  plateau  at  the  summit  is  seen  also 
in  some  cases  of  mitral  stenosis  and  renal  disease,  and  is  not  peculiar 
to  aortic  stenosis,  but  taken  in  connection  with  the  other  signs  of  the 
disease  it  has  great  value  in  diagnosis. 

(3)    The  Thrill. 

In  the  majority  of  cases  an  intense  purring  vibration  may  be  felt 
if  the  hand  is  laid  over  the  upper  portion  of  the  sternum,  especially 
over  the  second  right  intercostal  space.  This  thrill  is  continued 
into  the  carotids,  can  occasionally  be  felt  at  the  apex,  and  rarely  over 
a  considerable  area  of  the  chest.  It  is  a  very  important  aid  in  the 
diagnosis  of  aortic  stenosis,  but  is  by  no  means  pathognomonic,  since 
aneurism  may  produce  a  precisely  similar  vibration  of  the  chest  wall. 

The  heart  is  slightly  enlarged  to  the  left  and  downward  as  a  rule, 
but  the  apex  impulse  is  unusually  indistinct,  "a  well-defined  and 
deliberate  push  of  no  great  violence  "  (Broadbent) .  Corresponding  to 
the  protracted  sustained  systole  the  first  sound  at  the  apex  is  dull  and 
long,  but  not  very  loud. 

Diagnosis  of  A  ortic  Stenosis  from  the  Etiology. 

Post  mortem  experience  has  taught  me  that  in  practically  all  long 
standing  cases  of  "rheumatic"  endocarditis  affecting  the  aortic  valve, 
stenosis  as  well  as  regurgitation  is  present.  Hence  if  these  etiological 
factors  can  be  recognized  and  if  there  is  clear  evidence  of  aortic 
regurgitation,  it  is  pretty  safe  to  postulate  the  existence  of  aortic 
stenosis  as  well,  whatever  the  physical  signs. 

Differential  Diagnosis . 

A  systolic  murmur  heard  loudest  in  the  second  right  intercostal 
space  is  by  no  means  peculiar  to  aortic  stenosis,  but  may  be  due  to 
any  of  the  following  conditions : 

(a)  Roughening,  stiffness,  fenestration,  or  slight  congenital  mal- 
formation of  the  aortic  valves. 

ih)   Roughening  or  diffuse  dilatation  of  the  arch  of  the  aorta. 

(c)   Aneurism  of  the  aorta  or  innominate  artery. 

{d)  Functional  murmurs. 

(e)  Pulmonary  stenosis. 

(/)   Open  ductus  arteriosus,  and  other  congenital  lesions. 


VALVULAR  LESIONS  231 

(g)   Mitral  regurgitation. 

(a  and  b)  The  great  majority  of  systolic  murmurs  at  the  base  of 
the  heart,  first  appearing  after  middle  life,  are  due  to  the  causes  men- 
tioned above  under  a,  b,  and  c.  In  such  cases  the  murmur  is  usually 
combined  with  accentuation  and  ringing  quality  of  the  aortic  second 
sound  owing  to  the  arterio-sclerosis  and  high  arterial  tension  associated 
with  the  changes  which  produce  the  murmur.  This  accentuation  of 
the  aortic  second  sound  enables  us,  except  in  rare  cases,  to  exclude  aortic 
stenosis,  in  which  the  intensity  of  the  aortic  second  sound  is  almost 
always  much  reduced. 

Diffuse  dilatation  of  the  aorta,  such  as  often  accompanies  aortic 
regurgitation,  is  a  frequent  cause  of  a  systolic  murmur  loudest  in  the 
second  right  interspace.  This  may  be  recognized  in  certain  cases  by 
the  characteristic  area  of  pulsation  and  of  dulness  on  percussion;  by  its 
association  with  aortic  regurgitation  of  long  standing  (see  Fig.  153). 

Roughening  of  the  intima  of  the  aorta  (endaortitis)  is  always  to  be 
suspected  in  elderly  patients  with  calcified  and  tortuous  peripheral 
arteries,  and  such  a  condition  of  the  aorta  doubtless  favors  the  occur- 
rence of  a  murmur,  especially  when  accompanied  by  a  slight  degree 
of  dilatation.  The  absence  of  a  thrill  and  a  long,  slow  pulse  with  a 
low  maximum  serves  to  distinguish  such  murmurs  from  those  of 
aortic  stenosis. 

(c)  Aneurism  of  the  ascending  arch  of  the  aorta  or  of  the  innomin- 
ate artery  may  give  rise  to  every  sign  of  aortic  stenosis  except  the 
characteristic  pulse  and  the  diminution  of  the  aortic  second  sound. 
In  aneurism  we  may  have  a  well-marked  tactile  thrill  and  a  loud  sys- 
tolic murmur  transmitted  into  the  neck,  but  there  is  usually  some 
abnormal  pulsation  to  be  felt,  a  characteristic  ^-ray  shadow  to  be  seen, 
and  often  some  difference  in  the  pulses  or  in  the  pupils,  as  well  as  a 
history  of  pain  and  symptoms  of  pressure  upon  the  trachea  and 
bronchi  or  recurrent  laryngeal  nerve.  In  aneurism  the  aortic  second 
sound  is  usually  loud  and  accompanied  by  a  shock,  and  the  pulse 
shows  none  of  the  characteristics  of  aortic  stenosis. 

(d)  Functional  murmurs,  sometimes  known  as  "haemic,"  are 
occasionally  best  heard  in  the  aortic  area  instead  of  in  their  usual  situa- 
tion (second  left  intercostal  space) .  They  occur  especially  in  young, 
anaemic  persons,  are  not  accompanied  by  any  cardiac  enlargement,  by 
any  palpable  thrill,  any  diminution  in  the  aortic  second  sound,  or  any 
distinctive  abnormalities  in  the  pulse. 

(e)  Pulrnonary  stenosis,  a  rare  lesion,  is  manifested  by  a  systolic 
murmur  and  by  a  thrill  whose  maximum  intensity  is  usually  on  the 


232  PHYSICAL  DIAGNOSIS 

left  side  of  the  sternum.  In  the  rare  cases  in  which  this  murmur  is 
best  heard  in  the  aortic  area  it  may  be  distinguished  from  the  murmur 
of  aortic  stenosis  by  the  fact  that  it  is  not  transmitted  into  the  vessels 
of  the  neck,  has  no  effect  upon  the  aortic  second  sound,  and  is  not 
accompanied  by  the  characteristic  changes  in  the  pulse. 

(/)  The  murmur  due  to  persistence  of  the  ductus  arteriosus  may 
last  through  systole  and  into  diastole;  it  may  be  accompanied  by  a 
thrill,  but  does  not  affect  the  aortic  second  sound  nor  the  pulse.  Most 
of    the    other  congenital  lesions  can  be  recognized  by  their  history. 

(g)  The  systolic  murmur  of  aortic  stenosis  may  be  heard  loudly  at 
the  apex,  and  hence  the  lesion  may  be  mistaken  for  mitral  regurgitation. 
But  the  maximum  intensity  of  the  murmur  of  aortic  stenosis  is  almost 
invariably  in  the  aortic  area,  and  its  association  with  a  thrill  and  a 
long,  slow  pulse  should  enable  us  easily  to  differentiate  the  two  lesions. 

By  the  foregoing  differentiae  aortic  stenosis  may  be  distin- 
guished from  the  other  conditions  which  resemble  it,  provided  it 
predominates  over  the  regurgitation  associated  with  it,  but  unfortunately 
this  is  not  very  common.  As  a  rule,  it  is  fairly  well  balanced  or 
neutralized  by  the  accompanying  aortic  regurgitation,  and  its  char- 
acteristic signs  are  therefore  obscured  or  greatly  modified  by  the  signs 
of  the  latter  disease.  We  may  suspect  stenosis:  (a)  In  all  young 
(rheumatic)  patients  with  long-standing  aortic  regurgitation.^  (6) 
In  older  (syphilitic  or  arterio-sclerotic)  patients  who  show,  besides 
the  signs  of  aortic  regurgitation,  palpable  thrill  in  the  aortic  area 
transmitted  into  the  great  vessels,  a  modification  of  the  Corrigan  pulse 
in  the  direction  of  the  ''pulsus  tardus,  rarus,  parvus,"  and  less  visible 
arterial  pulsation  than  is  to  be  expected  in  pure  aortic  regurgitation. 

Occasionally  one  can  watch  the  development  of  an  aortic  stenosis 
out  of  what  was  formerly  a  pure  regurgitant  lesion,  the  stenosis  gradu- 
ally modifying  the  characteristics  of  the  previous  condition.  One 
must  be  careful,  however,  to  exclude  a  relative  mitral  insufficiency 
which,  as  has  been  already  mentioned  above,  is  very  apt  to  supervene 
in  cases  of  aortic  disease,  owing  to  dilatation  of  the  mitral  orifice,  and 
which  may  modify  the  characteristic  signs  of  aortic  regurgitation 
very  much  as  aortic  stenosis  does. 

Tricuspid  Regurgitation. 

Endocarditis  affecting  the  tricuspid  valve  is  rare  in  post-foetal  life; 
in  the  foetus  it  is  not  so  uncommon.     In  cases  of  ulcerative  or  malig- 

^  Because  post-mortem  experience  shows  that  in  cases  of  this  type  stenosis  and  insuffi- 
ciency are  usually  combined. 


VALVULAR  LESIONS  233 

nant  endocarditis  occurring  in  adult  life,  the  tricuspid  valve  is  occa- 
sionally involved,  but  the  majority  of  cases  of  tricuspid  disease  occur 
as  a  result  of  disease  of  the  mitral  valve  and  in  the  following  manner : 
Hypertrophy  of  the  right  ventricle  occurs  as  a  result  of  the  mitral 
disease,  and  is  followed  in  time  by  dilatation ;  with  this  dilatation  comes 
a  stretching  of  the  ring  of  insertion  of  the  tricuspid  valve,  and 
hence  a  regurgitation  through  that  valve.  Tricuspid  regurgitation, 
then,  occurs  in  the  latest  stages  of  almost  every  case  of  mitral  disease 
and  sometimes  during  the  earlier  attacks  of  failing  compensation. 

Out  of  405  autopsies  at  Guy's  Hospital  in  which  evidence  of 
tricuspid  regurgitation  was  found,  271,  or  two-thirds,  resulted  from 
mitral  disease,  68  from  myocardial  degeneration,  55  from  pulmonary 
disease  (bronchitis,  emphysema,  cirrhosis  of  the  lung).  Very  few  of 
these  cases  had  been  diagnosed  during  life,  and  in  all  of  them  the 
valve  was  itself  healthy  but  insufficient  to  close  the  dilated  orifice. 

Gibson  and  some  other  writers  believe  that  temporary  tricuspid 
regurgitation  is  the  commonest  of  all  valve  lesions,  and  results  from 
weakening  of  the  right  ventricle  in  connection  with  states  of  anae- 
mia, gastric  atony,  fever,  and  many  other  conditions.  It  is  very 
difficult  to  prove  or  disprove  such  an  assertion. 

Tricuspid  regurgitation  is  often  referred  to  as  serving  like  the 
opening  of  a  ''safety  valve''  to  relieve  a  temporary  pulmonary  en- 
gorgement. This  "safety-valve"  action,  however,  may  be  most 
disastrous  in  its  consequences  to  the  organism  as  a  whole,  despite 
the  temporary  relief  which  it  affords  to  the  overfilled  lungs.  The 
engorgement  is  simply  transferred  to  the  liver  and  thence  to  the 
abdominal  organs  and  the  lower  extremities,  so  that  as  a  rule  the 
advent  of  tricuspid  regurgitation  is  recognized  not  as  a  relief  but 
as  a  serious  and  probably  fatal  disaster. 

Physical  Signs. 

(i)  A  systolic  murmur  heard  loudest  at  or  near  the  fifth  left 
costal  cartilage. 

(2)  Systolic  venous  pulsation  in  the  jugulars  and  in  the  liver. 

(3)  Engorgement  of  the  right  auricle  producing  an  area  of  dulness 
beyond  the  right  sternal  margin. 

(4)  Intense  cyanosis. 

(5)  Ascites  and  oedema  of  the  legs. 

(i)  The  Murmur. — -The  maximum  intensity  of  the  systolic  miur- 
mur  of  tricuspid  regurgitation  is  usually  near  the  junction  of  the  fifth 


234 


PHYSICAL  DIAGNOSIS 


or  sixth  left  costal  cartilages  with  the  sternum.  Leube  finds  the 
murmur  a  rib  higher  up,  but  it  is  generally  agreed  that  the  tricuspid 
area  is  a  large  one,  so  that  the  murmur  may  be  heard  anywhere 
over  the  lower  part  of  the  sternum  or  even  to  the  right  of  it.  On  the 
other  hand,  there  are  some  tricuspid  murmurs  which  are  best  heard 
at  a  point  midway  between  the  apex  impulse  and  the  ensiform  carti- 
lage. The  murmur  is  not  widely  transmitted  and  is  usually  inaudi- 
ble in  the  back;  at  the  end  of  expiration  its  intensity  is  increased. 

In  some  cases  we  have  no  evidence  of  tricuspid  regurgitation 
other  than  the  murmur  just  described,  but — 

(2)  Of  more  importance  in  diagnosis  is  the  presence  of  a  sys- 
tolic pulsation  in  the  external  jugular  veins  and  of  the  liver,  which 
unfortunately  is  not  always  present,  but  which  when  present  is 
pathognomonic.     I   have   already  explained    (see   p.  86)  the  distinc- 


Systolic  murmur.    " 


Enlarged  and  pul- 
sating liver. 


Fig.  164. — Tricuspid  Regurgitation.     The  murmur  is  heard  best  over  the  shaded  area. 


tion  between  true  systolic  jugular  pulsation,  and  simple  presystolic 
undulation  or  distention  of  the  same  veins,  which  has  no  necessary 
relation  to  this  disease.  The  decisive  test  is  the  effort  permanently 
to  empty  the  vein  by  stroking  it  upward  from  below.  If  it  instantly 
refills  from  below  and  continues  to  pulsate,  tricuspid  regurgitation 
is  almost  certainly  present.  If,  on  the  other  hand,  it  does  not  refill 
from  below,  the  cause  must  be  sought  elsewhere. 

Pulsation  in  the  liver  must  be  distinguished  from  the  "jogging" 
motion  which  may  be  transmitted  to  it  from  the  abdominal  aorta  or 
from  the  right  ventricle.  To  eliminate  these  transmitted  impulses 
one  must  be  able  to  grasp  the  liver  bimanually,  one  hand  in  front  and 


VALVULAR  LESIONS  235 

one  resting  on  the  lower  ribs  behind,  and  to  feel  it  divStinctly  expand 
with  every  systole,  or  else  to  take  its  edge  in  the  hand  and  to  feel  it 
enlarge  in  one's  grasp  with  every  beat  of  the  heart.  Pressure  upon  the 
liver  often  causes  increased  distention  and  pulsation  of  the  external 
jugulars  if  tricuspid  regurgitation  is  present. 

(3)  Enlargement  of  the  heart,  both  to  the  right  and  to  the  left,  as 
well  as  downward,  can  usually  be  demonstrated.  In  rare  cases  a 
dilatation  of  the  right  auricle  may  be  suggested  by  a  percussion  outline 
such  as  that  shown  in  Fig.  164. 

The  pulmonic  second  sound  is  usually  not  accented.  The  impor- 
tance of  this  in  differential  diagnosis  will  be  mentioned  presently.  If 
a  progressive  diminution  in  the  intensity  of  the  sound  occurs  under 
observation,  the  prognosis  is  very  grave. 

(4)  Cyanosis  is  usually  very  great,  and  dyspnoea  and  general  dropsy 
often  make  the  patient's  condition  a  desperate  one. 

Differential  Diagnosis. 

The  statistics  of  the  cases  autopsied  at  the  Massachusetts  General 
Hospital  show  that  tricuspid  regurgitation  is  less  often  recognized 
during  life  than  any  other  valvular  lesion.  The  diagnosis  was  made 
ante  mortem  on  only  five  out  of  twenty-nine  cases.  This  is  due  to 
the  following  facts : 

(a)  Tricuspid  regurgitation  may  be  present  and  yet  give  rise  to  no 
physical  signs  which  can  be  recognized  during  life. 

(&)  Tricuspid  regurgitation  occurs  most  frequently  in  connection 
with  mitral  regurgitation;  hence  its  signs  are  frequently  masked  by 
those  of  the  latter  lesion.  It  is,  therefore,  a  matter  of  great  importance 
as  well  as  of  great  difficulty  to  distinguish  tricuspid  regurgitation  from 

(i)    Mitral  Regurgitation. 

The  difficulties  are  obvious.  The  murmur  of  mitral  regurgitation 
has  its  maximum  intensity  not  more  than  an  inch  or  two  from  the 
point  at  which  the  tricuspid  murmur  is  best  heard.  Both  are  systolic 
in  time.     They  are,  therefore,  to  be  distinguished  only — 

(a)  In  case  we  can  demonstrate  that  there  are  two  areas  in  which 
a  systolic  murmur  is  heard  with  relatively  great  intensity,  with  an 
intervening  space  over  which  the  murmur  is  less  clearly  to  be  heard' 
(see  Fig.  165). 

ih)  Occasionally  the  two  systolic  murmurs  are  of  different  pitch 
or  of  different  quality,  and  may  be  thus  distinguished. 


236  PHYSICAL  DIAGNOSIS 

(c)  Tricuspid  murmurs  are  not  transmitted  into  the  left  axilla 
and  are  rarely  audible  in  the  back,  and  this  fact  is  of  value  in  case  we 
have  to  distinguish  between  uncomplicated  tricuspid  regurgitation 
and  uncomplicated  mitral  regurgitation.  Unfortunately  these  le- 
sions are  very  apt  to  occur  simultaneously,  so  that  in  practice  our 
efforts  are  generally  directed  toward  distinguishing  between  a  pure 
mitral  regurgitation  and  one  complicated  by  tricuspid  regurgitation. 

(d)  In  cases  of  doubt  the  phenomena  of  venous  pulsation  in  the 
jugulars  and  in  the  liver  are  decisive  if  present,  but  their  absence 
proves  nothing. 

(e)  Accentuation  of  the  pulmonic  second  sound  is  almost  inva- 
riably present  in  uncomplicated  mitral  disease  and  is  apt  to  disap- 
pear in  case  the  tricuspid  begins  to  leak,  since  engorgement  of  the 


Fig.   165. — Two    Systolic  Murmurs   (Mitral  and  Tricuspid)   with  a  "Vanishing  Point" 

between. 


lungs  is  thereby  for  the  time  relieved,  but  in  many  cases  the  pul- 
monic second  sound  remains  most  unaccountably  strong  even  when 
the  tricuspid  is  obviously  leaking. 

(2)  From  "functional"  systolic  murmurs  tricuspid  insufficiency 
may  generally  be  distinguished  by  the  fact  that  its  murmur  is  best 
heard  in  the  neighborhood  of  the  ensiform  cartilage,  and  not  in  the 
second  right  intercostal  space  where  most  functional  murmurs  have 
their  seat  of  maximum  intensity.  Functional  murmurs  are  unac- 
companied by  venous  pulsation,  cardiac  dilatation,  or  cyanosis. 

(3)  Occasionally  a  pericardial  friction  rub  simulates  the  mur- 
mur of  tricuspid  insufhciency,  but,  as  a  rule,  pericardial  friction  is 


VALVULAR  LESIONS  237 

much  more  irregular  in  the  time  of  its  occurrence  and  is  not  regularly 
synchronous  with  any  definite  portion  of  the  cardiac  cycle. 

Tricuspid  Stenosis. 

One  of  the  rarest  of  valve  lesions  is  narrowing  of  the  tricuspid 
valve.  Only  8  cases  (none  recognized  in  life)  have  come  under  my 
observation,  and  in  1S98,  Herrick  was  able  to  collect  but  154  cases 
from  the  world's  literature.  Out  of  these  154  cases,  138,  or  90  per 
cent.,  were  combined  with  mitral  stenosis,  and  only  12  times  has  tri- 
cuspid stenosis  been  known  to  occur  alone. ^  These  observations  ac- 
count for  the  fact  that  tricuspid  stenosis  has  hardly  ever  been  recog- 
nized during  life,  since  the  murmur  to  which  it  gives  rise  is  identical 
in  time  and  quality  and  nearly  identical  in  position  with  that  of  mitral 
stenosis.  Narrowing  of  the  tricuspid  valve  is  to  be  diagnosed,  there- 
fore, only  by  the  recognition  of  a  presystolic  murmur  best  heard  in 
the  tricuspid  area  and  distinguished  either  by  its  pitch,  quality,  or 
position  from  the  other  presystolic  murmur  due  to  the  mitral  stenosis 
which  is  almost  certain  to  accompany  it. 

The  heart  is  usually  enlarged,  especially  in  its  transverse  direc- 
tion, but  the  enlargement  is  just  such  as  mitral  stenosis  produces, 
and  does  not  aid  our  diagnosis  at  all. 

The  diagnosis  is  still  further  complicated  in  many  cases  by  the 
presence  of  an  aortic  stenosis  in  addition  to  a  similar  lesion  a:  the 
tricuspid  and  mitral  valves,  so  that  it  seems  likely  that  in  the  future 
as  in  the  past  the  lesion  will  be  discovered  first  at  autopsy. 

One  may  be  led  occasionally  to  suspect  the  hidden  presence  of 
tricuspid  stenosis,  if  a  case  of  supposedly  pure  mitral  stenosis  does 
not  yield  to  treatment  in  the  usual  way. 

Pulmonary  Regurgitation. 

Organic  disease  of  the  pulmonary  valve  is  excessively  rare  in 
post-foetal  life,  but  may  occur  as  part  of  an  acute  ulcerative  or  septic 
endocarditis.  A  temporary  functional  regurgitation  through  the 
pulmonary  valve  may  be  brought  about  by  any  cause  producing 
very    high    pressure   in    the    pnlnionary    artery.     I    have    known    two 

^  Out  of  87  cases  collected  from  the  post-mortem  records  of  Guy's  Hospital,  85, 
or  97  per  cent.,  were  associated  with  still  more  extensive  mitral  stenosis.  At  the  Mass. 
General  Hospital  all  of  the  8  cases  of  tricuspid  stenosis  found  at  autopsy  were  associated 
with  mitral  stenosis  as  well. 


238  PHYSICAL  DIAGNOSIS 

medical  students  with  perfectly  healthy  hearts  who  were  able,  by 
prolonged  holding  of  the  breath,  to  produce  a  short,  high-pitched 
diastolic  murmur  best  heard  in  the  second  and  third  left  intercostal 
spaces  and  ceasing  as  soon  as  the  breath  was  let  out.  Of  the  occur- 
rence of  a  murmur  similarly  produced  under  pathological  condi- 
tions, especially  in  mitral  stenosis,  much  has  been  written  by  Graham 
Steell. 

From  the  diastolic  murmur  of  aortic  regurgitation  we  may  dis- 
tinguish the  diastolic  murmur  of  pulmonary  incompetency  by  the 
fact  that  the  latter  is  best  heard  over  the  pulmonary  valve,  is  never 
transmitted  to  the  apex  of  the  heart  nor  to  the  great  vessels,  and  is 
never  associated  with  a  Corrigan  pulse  nor  with  capillary  pulsation.^ 
The  right  ventricle  is  hypertrophied,  the  pulmonic  second  sound  is 
sharply  accented  and  followed  immediately  by  the  murmur.  Evi- 
dences of  septic  embolism  of  the  lungs  are  frequently  present  and 
assist  us  in  diagnosis.  The  regurgitation  which  may  take  place 
through  the  rigid  cone  of  congenital  pulmonary  stenosis  is  not  recog- 
nizable during  life. 

Pulmonary  Stenosis. 

Among  the  rare  congenital  lesions  of  the  heart  valves  this  is  prob- 
ably the  commonest.  The  heart,  and  particularly  the  right  ventricle, 
is  usually  much  enlarged.  There  is  a  history  of  cyanosis  and  dyspnoea 
since  birth.  Pulmonary  tuberculosis  complicates  from  one-fourth 
to  one-third  of  all  cases.  A  systolic  thrill  is  usually  to  be  felt  in  the 
second  left  intercostal  space,  and  a  loud  systolic  murmur  is  heard 
in  the  same  area.     The  pulmonic  second  sound  is  weak. 

The  region  in  which  this  murmur  is  best  heard  has  been  happily 
termed  the  "region  of  romance"  on  account  of  the  multiplicity  of 
mysterious  murmurs  which  have  been  heard  there.  The  systolic 
murmur  of  pulmonary  stenosis  must  be  distinguished  from 

(a)  Functional  murmurs  due  to  anaemia  and  debility  or  to  severe 
muscular  exertion,  and  possibly  associated  with  a  dilatation  of  the 
conus  arteriosus. 

(&)  Uncovering  of  the  conus  arteriosus  through  lack  of  expansion 
of  the  lung. 

(c)   Aortic  stenosis. 

'  By  registering  the  variations  of  pressure  in  the  tracheal  column  of  air  Gerhardt  has 
shown  graphically  that  a  systolic  pulsation  of  the  pulmonary  capillaries  may  occur  in 
pulmonary  regurgitation.  With  the  stethoscope  a  systoKc  whiff  may  be  heard  all  over  the 
lungs. 


VALVULAR  LESIONS  239 

(d)  Mitral  regurgitation. 

(e)  Aneurism. 

(/)   Roughening  of  the  intima  of  the  aortic  arch. 

(g)   Other  congenital  lesions  such  as  septum  defects. 

(a  and  b)  Functional  murmurs,  and  those  produced  in  the  conus 
arteriosus,  are  rarely  if  ever  accompanied  by  a  thrill,  are  rarely  so 
loud  as  the  murmur  of  pulmonary  stenosis,  and  are  not  associated 
with  dyspnoea,  cyanosis,  and  enlargement  of  the  right  ventricle. 

(c)  The  murmur  of  aortic  stenosis  is  usually  upon  the  right  side 
of  the  sternum  and  is  transmitted  to  the  neck,  whereas  the  murmur 
of  pulmonary  stenosis  is  never  so  transmitted  and  is  not  associated 
with  characteristic  changes  in  the  pulse  (see  above,  p.  229). 

(d)  The  murmur  of  tnitral  regurgitation  is  occasionally  loudest 
in  the  region  of  the  pulmonary  valve,  but  differs  from  the  murmur 
of  pulmonary  stenosis  in  being,  as  a  rule,  transmitted  to  the  back 
and  axilla  and  associated  with  an  accentuation  of  the  pulmonary 
second  sound. 

(e)  Aneurism  may  present  a  systolic  murmur  and  thrill  similar 
to  those  found  in  pulmonary  stenosis,  but  may  usually  be  distin- 
guished from  the  latter  by  the  presence  of  the  positive  signs  of  aneur- 
ism, viz.— pulsation,  and  dulness  in  the  region  of  the  murmur,  and 
signs  of  pressure  on  the  trachea  or  on  other  structures  in  the 
mediastinum. 

(/)  Roughening  of  the  aortic  arch  occurs  after  middle  life,  while 
pulmonary  stenosis  is  usually  congenital.  The  murmur  due  to  rough- 
ening may  be  transmitted  into  the  carotids;  that  of  pulmonary 
stenosis  never.  Enlargement  of  the  right  ventricle  is  characteristic 
of  pulmonary  stenosis,  but  not  of  aortic  roughening. 

(g)  It  is  practically  impossible  to  distinguish  pulmonary  stenosis 
from  septum  defects,  especially  as  the  two  are  often  combined. 

Combined  Valvular  Lesions. 

It  is  essential  that  the  student  should  understand  from  the  first 
that  the  number  of  miurmurs  audible  in  the  precordia  is  no  gauge 
for  the  number  of  valve  lesions.  We  may  have  four  distinct  murmurs, 
yet  every  valve  sound  except  one.  This  is  often  the  case  in  aortic 
regurgitation — systolic  and  diastolic  murmiu-s  at  the  base  of  the 
heart,  systolic  and  presystolic  at  the  apex,  yet  no  valve  injured 
except  the  aortic.  In  such  a  case  the  systolic  aortic  murmur  is  due 
to  roughening  of  the  aortic  valve.     The  systolic  apex  murmur  results 


240  PHYSICAL  DIAGNOSIS 

from  relative  mitral  leakage  (with  a  sound  valve).  The  presystolic 
apex  murmur  is  of  the  "Flint"  type.  Hence  in  this  case  the  diastolic 
murmur  alone  of  the  four  audible  murmurs  is  due  to  a  valvular 
lesion. 

It  is  a  good  rule  not  to  multiply  causes  unnecessarily,  and  to 
explain  as  many  signs  as  possible  under  a  single  hypothesis.  In 
the  above  example  the  mitral  leak  might  be  due  to  an  old  endocar- 
ditis, and  there  might  be  mitral  stenosis  and  aortic  stenosis  as  well, 
but  since  we  can  explain  all  the  signs  as  results — direct  and  indirect 
— of  one  lesion  (aortic  regurgitation)  it  is  better  to  do  so,  and  post- 
mortem experience  shows  that  our  diagnosis  is  more  likely  to  be 
right  when  it  is  made  according  to  this  principle. 

The  most  frequent  combinations  are: 

(i)   Mitral  regurgitation  with  mitral  stenosis. 

(2)  Aortic  regurgitation  with  mitral  regurgitation  (with  or  with- 
out stenosis). 

(3)  Aortic  regurgitation  with  aortic  stenosis,  with  or  without 
mitral  disease. 

(i)  Double  Mitral  Disease. 

(a)  It  very  frequently  happens  that  the  mitral  valve  is  found 
to  be  both  narrowed  and  incompetent  at  autopsy  when  only  one  of 
these  lesions  had  been  diagnosed  during  life.  In  fact  mitral  steno- 
sis is  almost  never  found  at  autopsy  without  such  a  stiffening  of  the 
orifice  as   would   produce   an   associated  regurgitation,  so  that  it  is 

1st  _ 

III,  2iul  ,il| 


Fig.    166. — Mitral   Stenosis   and   Regurgitation,   showing  relation  of  murmur  to 
first  heart  sound. 

fairly  safe  to  assume,  whenever  one  makes  the  diagnosis  of  mitral 
stenosis,  that  mitral  regurgitation  is  present  as  well,  whether  it  is 
possible  to  hear  any  regurgitant  murmur  or  not  (see  Fig.  166). 

(6)  On  the  other  hand,  with  a  double  mitral  lesion  one  may 
have  only  the  regurgitant  murmur  at  the  mitral  valve  and  nothing 
to  suggest  stenosis  unless  it  be  a  surprising  sharpness  of  the  first 
mitral  sound.  In  chronic  cases  the  changeableness  of  the  murmurs 
both  in  type  and  position  is  extraordinary.  One  often  finds  at  one 
visit  evidences  of  mitral  stenosis  and  at  another  evidences  of  mitral 


VALVULAR  LESIONS 


241 


regurgitation  alone.  Either  murmur  may  disappear  altogether  for 
a  time  and  reappear  subsequently.  This  is  peculiarly  true  of  the  pre- 
systolic murmur,  which  is  notoriously  one  of  the  most  fleeting  and 
uncertain  of  all  physical  signs. 

As  a  rule  the  same  inflammatory  changes  which  produce  mitral 
regurgitation  in  early  life  result,  as  they  extend,  in  a  narrowing  of  the 
mitral  valve,  so  that  the  signs  of  stenosis  come  to  predominate  in 
later  years.  Coincidently  with  this  narrowing  of  the  diseased  valve 
a  certain  amount  of  improvement  in  the  patient's  symptoms  may 
take  place,  and  Rosenbach  regards  the  advent  of  stenosis  in  such  a 
case  as  an  attempt  at  a  regenerative  or  compensatory  change.  In 
many  cases,  however,  no  such  amelioration  of  the  symptoms  follows. 

(2)  Aortic  Regurgitation  with  Mitral  Disease. 

The  signs  of  mitral  disease  occurring  in  combination  with  aortic 
regurgitation  do  not  differ  essentially  from  those  of  pure  mitral 
disease  except  that  the  enlargement  of  the  heart  is  apt  to  be  more 


Systolic  murmur 

over       dilated j~ 

aortic  arch. 


Maximum  intensity 
and  diastolic  mur- 
mur, conducted 
up  and  down. 


'Systolic  murmur. 


Fig.  167. — Aortic  and  Mitral  Regurgitation.     The  shaded  areas  are  those  in  which  the 

murmurs  are  loudest. 


general  and  correspond  less  exclusively  to  the  right  ventricle  (see 
Figs.  167  and  168) .  The  manifestations  of  the  aortic  lesion,  on  the  other 
hand,  are  considerably  modified  by  their  association  with  the  mitral 
disease.  The  Corrigan  pulse  is  distinctly  less  sharp  at  the  summit 
and  rises  and  falls  less  abruptly.  Capillary  pulse  is  less  likely  to  be 
present,  and  the  throbbing  of  the  peripheral  arteries  is  less  often 
visible. 

16 


242  PHYSICAL  DIAGNOSIS 

(3)  Aortic  Regurgitation  with  Aortic  Stenosis. 

If  the  aortic  valves  are  narrowed  as  well  as  incompetent,  we 
find  very  much  the  same  modification  of  the  physical  signs  charac- 
teristic of  aortic  regurgitation  as  is  produced  by  the  advent  of  a 
mitral  lesion;  that  is  to  say,  the  throbbing  in  the  peripheral  arteries 
is  less  violent,  the  characteristics  of  the  radial  pulse  are  less  marked, 

1st  1st 

li,  2nd  lllli  2nd 


J 


m MIIIIIIIIMMI  I     IHIIMnillMllli 


Fig.  i58. — Showing  Relation  of  Murmurs  to  Heart  Sound  in  Regurgitation  at  the  Aortic 

and  Mitral  Valves. 

and  the  capillary  pulsation  is  not  always  to  be  obtained  at  all.  Indeed, 
this  blunting  of  all  the  typical  manifestations  of  aortic  regurgitation 
may  give  us  material  aid  in  the  diagnosis  of  aortic  stenosis,  provided 
always  that  the  mitral  valve  is  still  performing  its  function.^ 

(4)   The  association  of  mitral  disease  with  tricuspid  insufficiency 
has  been  already  described  on  p.  208. 

^  Some  astonishing  exceptions  to  this  rule  have  been  mentioned  on  pages  227  and  230. 


CHAPTER  XII. 

PARIETAL  DISEASE.-CARDIAC  NEUROSES.- 

CONGENITAL  MALFORMATIONS  OF 

THE  HEART. 

Parietal  Disease  of  the  Heart. 

AciUe  Myocarditis. 

The  myocardium  is  seriously,  though  not  incurably,  afifected  in 
all  continued  fevers,  owing  less  to  the  fever  itself  than  to  the  tox- 
aemia associated  with  it.  "Cloudy  swelling,"  or  acute  degenera- 
tion of  the  muscle  fibres,  is  produced  by  relatively  mild  infections, 
while  a  general  septicaemia  due  to  pyogenic  organisms  may  produce 
extensive /a//y  degeneration  of  the  heart  within  a  few  days. 

The  physical  signs  are  those  of  cardiac  weakness.  The  most 
significant  change  is  in  the  quality  of  the  first  sound  at  the  apex 
of  the  heart,  which  becomes  gradually  shorter  until  its  quality  is 
like  that  of  the  second  sounds,  while  in  some  cases  its  feebleness 
makes  the  second  sounds  seem  accented  by  comparison.  Soft  blow- 
ing systolic  murmurs  may  develop  at  the  pulmonary  orifice,  less 
often  at  the  apex  or  over  the  aortic  valve. 

The  apex  impulse  becomes  progressively  feebler  and  more  like 
a  tap  than  a  push.  Irregularity  and  increasing  rapidity  are  ominous 
signs  which  may  be  appreciated  in  the  radial  pulse,  but  still  better  by 
auscultation  of  the  heart  itself.  In  most  of  the  acute  infections, 
evidence  of  dilatation  of  the  weakened  cardiac  chambers  is  rarely  to 
be  obtained  during  life  (although  at  autopsy  it  is  not  infrequently 
found), ^  but  in  actite  articular  rheumatism  an  acute  dilatation  of  the 
heart  appears  to  be  a  frequent  complication,  independent  of  the 
existence  of  any  valvular  disease.  Attention  has  been  especially 
called  to  this  point  by  Lees  and  Boynton  {British  Med.  Jour.,  July 
2,  1898)  and  by  S.  West. 

Influenza  is  also  complicated  not  infrequently  by  acute  cardiac 
dilatation. 

^  Henchen's  recent  monograph  on  this  subject,"  Ueber  die  acute  Herzdilatation  bei 
acuten  Infectionskrankheiten,"  Jena,  1899,  does  not  seem  to  me  convincing. 

243 


244  PHYSICAL  DIAGNOSIS 

Weakened  Heart  ("Chronic  Myocarditis"). 

Fatty  or  fibroid  changes  in  the  heart  wall  occurring  in  chronic 
disease  may  result  from  coronary  sclerosis  and  imperfect  nutrition 
of  the  myocardium,  but  in  many  cases  no  lesions  are  found  post 
mortem  in  the  heart,  whose  muscle  weakens  as  a  result  of  long-con- 
tinued overwork  against  an  increased  arterial  resistance  (nephritis, 
arterio-sclerosis) . 

Whether  definite  myocardial  changes  are  present  or  not,  the  signs 
are  the  same. 

Physical  Signs  of  Weakened  Heart. 

For  the  sure  recognition  of  changes  in  the  myocardium  our  pres- 
ent methods  of  physical  examination  are  always  unsatisfactory 
and  often  wholly  inadequate.  Extensive  degenerations  of  the 
heart  wall  are  not  infrequently  found  at  autopsy  when  there  has 
been  no  reason  to  suspect  them  during  life.  On  the  other  hand, 
the  autopsy  often  fails  to  substantiate  a  diagnosis  of  degeneration 
of  the  heart  muscle,  although  all  the  physical  signs  traditionally 
associated  with  this  condition  were  present  during  life.  The  following 
figures  from  the  Massachusetts  General  Hospital  illustrate  these 
difficulties: 

Cases  of  fibrous  myocarditis  correctly  diagnosed.  ...  13  or  22  % 
Cases    of  fibrous   myocarditis  diagnosed  in  life,  but 

not  found  post  mortem 31  or  52  % 

Cases  of  fibrous  myocarditis  found  post  mortem,  but 

not  diagnosed  in  life 15  or  26  % 

Total  attempts 59 

To  a  considerable  extent,  therefore,  our  diagnosis  of  myocarditis  must 
depend  upon  the  history  and  symptoms  of  the  case;  physical  ex- 
amination can  sometimes  supplement  these,  sometimes  not.  Symp- 
toms of  cardiac  weakness  developing  in  a  man  past  middle  life,  espe- 
cially in  a  patient  who  shows  evidences  of  arterio-sclerosis  or  high 
blood  pressure,  or  who  has  suffered  from  the  effects  of  alcohol  and 
syphilis,  suggest  parietal  disease  of  the  heart,  fatty  or  fibroid.  The 
probability  is  increased  if  there  have  been  attacks  of  angina  ipectoris, 
Cheyne-Stokes  breathing,  or  of  syncope. 


PARIETAL  DISEASE  245 

Inspection  and  palpation  may  reveal  nothing  abnormal,  or  there 
may  be  an  unusually  diffuse,  slapping  cardiac  impulse  associated 
perhaps  with  a  displacement  of  the  apex  beat  to  the  left  and  down- 
ward. Marked  irregularity  of  the  heart  beat,  both  in  force  and  in 
rhythm,  is  sometimes  demonstrable  by  these  methods,  and  an  in- 
crease in  the  area  of  cardiac  dulness  may  be  demonstrable  in  case 
dilatation  has  followed  the  weakening  of  the  heart  wall.  Ausculta- 
tion may  reveal  nothing  abnormal  except  that  the  aortic  second 
sound  is  unusually  sharp;  in  some  cases  feeble  and  irregular  heart 
sounds  are  heard,  although  the  first  sound  at  the  apex  is  not  infre- 
quently sharp.  Blood  pressure  is  often  much  increased.  The 
sounds  may  be  reduplicated  and  "gallop  rhythm"  is  not  infrequent. 
If  the  mitral  sphincter  is  dilated,  or  the  papillary  muscles  are  weak- 
ened, as  not  infrequently  happens,  we  may  have  evidences  of  mitral 
regurgitation,  a  systolic  murmur  at  the  apex  heard  in  the  left  axilla 
and  back  with  accentuation  of  the  pulmonic  second  sound. 

Summary . 

1 .  The  causative  factors,  the  history  and  symptoms  of  the  case  and 
the  condition  of  other  organs  are  often  of  more  diagnostic  value  than 
is  the  physical  examination  of  the  heart  itself,  which  may  show 
nothing  abnormal. 

2.  Among  the  rather  unreliable  physical  signs,  those  most  often 
mentioned  are: 

(a)   Weakness  and  irregularity  of  the  heart  sounds. 

(6)   Increased  blocd  pressure. 

(c)    A  diffuse  slapping  cardiac  impulse. 

{d)   Reduplication  of  some  of  the  cardiac  sounds  (gallop  rhythm). 

(e)    Evidences  of  cardiac  dilatation. 

(/)  Murmurs — especially  the  murmur  of  mitral  insufficiency 
which  often  occurs  as  a  result  of  dilatation  of  the  valve  orifices  and 
weakening  of  the  cardiac  muscle. 

Differential  Diagnosis . 

We  have  to  distinguish  the  weakened  heart  from — 
(a)   Uncomplicated  valvular  lesions. 
(6)   Cardiac  neuroses. 

(a)  It  has  been  already  pointed  out  that  valvular  lesions  do 
not   necessarily   give   rise    to    any   murmurs  when  compensation  has 


246  PHYSICAL  DIAGNOSIS 

failed.  Under  such  circumstances  one  hears  only  irregular  and  weak 
heart  sounds,  as  in  myocardial  weakness.  The  history  of  a  long- 
standing valvular  trouble,  a  knowledge  of  the  previous  history  of  the 
case,  the  age,  method  of  onset,  and  the  blood  pressure  measurements 
may  assist  us  in  the  diagnosis.  Cases  of  weakened  heart  are  less  often 
associated  with  extensive  dropsy  than  are  cases  of  valvular  disease 
whose  compensation  has  been  ruptured. 

(b)  Weakness  and  irregularity  of  the  cardiac  sounds,  when  due  to 
"nervous"  affection  of  the  heart  and  unassociated  with  parietal  or 
valvular  changes,  is  usually  less  marked  after  slight  exertion.  The 
heart  "rises  to  the  occasion"  if  the  weakness  is  a  functional  one. 
On  the  other  hand,  if  any  serious  weakening  is  present,  the  signs 
and  symptoms  are  much  aggravated  by  any  exertion. 

In  some  cases  of  myocarditis  the  pulse  is  excessively  slow  and 
shows  no  signs  of  weakness.  This  point  will  be  referred  to  again 
in  the  chapter  on  Bradycardia. 

Fatty  Overgrowth. 

An  abnormally  large  accumulation  of  fat  about  the  heart  may 
be  suspected  if,  in  a  very  obese  person,  signs  of  cardiac  embarrass- 
ment (dyspnoea,  palpitation)  are  present,  and  if  on  examination  we 
find  that  the  heart  sounds  are  feeble  and  distant  but  preserve  the 
normal  difference  from  each  other.  When  the  heart  wall  is  seri- 
ously weakened  (as  in  the  later  weeks  of  typhoid),  the  heart  sounds 
become  more  alike  owing  to  the  shortening  of  the  first  sound. 

In  fatty  overgrowth  this  is  not  the  case. 

The  diagnosis,  however,  cannot  be  positively  made.  We  sus- 
pect it  under  the  conditions  above  described,  but  no  greater  cer- 
tainty can  be  attained. 

Fatty  Degeneration. 

There  are  no  physical  signs  by  which  fatty  degeneration  of  the 
heart  can  be  distinguished  from  other  pathological  changes  which 
result  in  weakening  the  heart  walls.  An  extensive  degree  of  fatty 
degeneration  is  often  seen  post  mortem  in  cases  of  pernicious  anaemia, 
although  the  heart  sounds  have  been  clear,  regular,  and  in  all  re- 
spects normal  during  life.  The  little  we  know  of  the  physical  signs 
common  to  fatty  degeneration  and  to  other  forms  of  parietal  dis- 
ease of  the  heart  has  been  included  in  the  section  on  Weakened 
Heart  (see  p.  243). 


DISTURBANCES  OF  RHYTHM  247 

Disturbances  of  Rhythm. 
Tachycardia  {Rapid  Heart). 

Simple  quickening  of  the  pulse  rate,  or  tachycardia,  which  may 
pass  altogether  unnoticed  by  the  patient  himself,  is  to  be  distinguished 
from  palpitation,  in  which  the  heart  beats,  whether  rapid  or  not, 
force  themselves  upon  the  patient's  attention. 

The  pulse  rate  may  vary  a  great  deal  in  health.  A  classmate 
of  mine  at  the  Harvard  Medical  School  had  a  pulse  rarely  slower 
than  ICO,  yet  his  heart  and  other  organs  were  entirely  sound.  Such 
cases  are  not  very  uncommon,  especially  in  women.  Temporarily 
the  pulse  rate  may  be  greatly  increased,  not  only  by  exercise  and 
emotion,  but  by  the  influence  of  fever,  of  gastric  disturbances,  or  of 
the  menopause.  Such  a  tachycardia  is  not  always  of  brief  duration. 
The  effects  of  a  great  mental  shock  may  produce  an  acceleration  of 
the  pulse  which  persists  for  days  or  even  weeks  after  the  shock. 

Among  organic  diseases  associated  with  tachycardia  and  weakening 
of  the  pulse  the  commonest  are  those  of  the  heart  itself.  Next  to  them, 
exophthalmic  goitre,  functional  neuroses  (some  of  them  sexual)  are  the 
most  frequent  causes  of  tachycardia. 

The  only  form  of  tachycardia  which  is  worthy  to  be  considered 
as  a  more  or  less  independent  malady  is 

Paroxysmal  Tachycardia. 

As  indicated  in  the  name,  the  attacks  of  this  disease  are  apt  to 
begin  and  to  cease  suddenly.  They  may  last  a  few  hours  or  several 
days.  The  pulse  becomes  frightfully  rapid,  often  200  per  minute  or 
more.  Bristowe  records  a  case  with  a  pulse  of  308  per  minute. 
In  the  radial  artery  the  pulse  beat  may  be  impalpable.  The  heart 
sounds  are  regular  and  clear,  but  the  diastolic  pause  is  shortened  and 
the  first  sound  becomes  short  and  "valvular,"  resembling  the  second 
(" tic-tac  heart").  Paroxysms  may  begin  and  end  with  absolute  sud- 
denness, the  heart  doubling  or  halving  its  rate  within  a  few  beats. 
Phlebograms  and  electrocardiograms  show  that  the  heart  beats  origi- 
nate in  the  auricle,  but  not  in  the  pace-maker  (see above,  p.  1 14) .  The 
paroxysm  may  be  associated  with  aphasia  and  abnormal  sensations 
in  the  left  arm.  Occasionally  the  heart  becomes  dilated,  and  oedema 
of  the  lungs,  albuminuria,  and  other  manifestations  of  stasis  appear. 
Usually,  however,  the  paroxysm  has  no  serious  results.  It  can  be 
distinguished  in  most  cases  from  the  tachycardia  of  cardiac  dilatation 
by  the  fact  that  the  heart  remains  perfectly  regular.     This  same  fact 


248  PHYSICAL  DIAGNOSIS 

also  assists  us  in  excluding  the  cardiac  neuroses  due  to  tobacco,  tea, 
and  other  poisons.  From  the  tachycardia  of  Graves'  disease  the  affec- 
tion now  in  consideration  differs  by  its  paroxysmal  and  intermittent 
character. 

Bradycardia  (Slow  Heart). 

In  many  healthy  adults  the  heart  seldom  beats  over  50  times  a 
minute. 

I.  Among  the  causes  which  may  produce  for  a  short  time  an 
abnormally  slow  heart-beat  are : 

(a)  Exhaustion;  for  example,  after  fevers,  after  parturition,  or 
severe  muscular  exertion. 

(b)  ToxcBmia;  for  example,  jaundice,  uraemia,  auto-intoxications  in 
dyspepsia. 

(c)  In  certain  hysterical  and  melancholic  states  and  in  neurotic 
children,  the  pulse  may  be  exceedingly  slow.  Pain  has  also  a  tendency 
to  retard  the  pulse. 

{d)  An  increase  of  intracranial  pressure,  as  in  meningitis,  cerebral 
hemorrhage,  depressed  fracture  of  the  skull.  Possibly  in  this  category 
belong  the  cases  of  bradycardia  sometimes  seen  in  epileptiform  or 
during  syncopal  attacks.  Bradycardia  from  any  one  of  these  causes  is 
apt  to  be  of  comparatively  short  duration. 

II.  Stokes-Adams'  disease  (due  to  a  lesion  of  the  bundle  of  His) 
refers  especially  to  a  paroxysmal  bradycardia  with  syncope,  yet  the 
pulse  may  remain  below  40  for  months,  though  strong  and  regular, 
and  the  patient  may  be  free  from  symptoms  of  any  kind.  The  rate 
of  the  heart-beat  cannot  be  estimated  by  counting  the  radial  pulse. 
Careful  study  of  the  jugular  motions,  especially  with  a  polygraph, 
usually  shows  that  some  auricular  beats  do  not  reach  the  ventricle 
(heart  block)  so  that  there  are  2  or  3  beats  in  the  jugular  for  every  i 
in  the  radial  (see  above,  p.  114). 

Arrhythmia. 

I.  Physiological  or  "Youthful"  Arrhythmia. — ^Arrhythmia,  or 
irregularity  in  the  force  or  rhythm  of  the  heart-beat,  is  to  a  certain 
extent  physiological.  The  heart  normally  beats  a  little  faster  and  a 
little  more  strongly  during  inspiration  than  during  expiration,  espe- 
cially during  childhood  and  youth.  Any  psychical  disturbance  or 
muscular  exertion  may  produce  irregularity  as  well  as  a  quickening  of 
the  heart-beat. 


DISTURBANCES  OF  RHYTHM  249 

In  children  the  pulse  is  especially  apt  to  be  irregular,  and  during 
sleep  some  children  show  that  modification  of  rhythm  known  as  the 
''paradoxical  pulse,"  which  consists  in  a  quickening  of  the  pulse  with 
diminution  in  volume  during  inspiration. 

2.  Arrhythmia  from  Pretnature  Contractions  {" Extr asystoles ") . — 
Isolated,  occasional  or  regularly  recurrent  interruptions  of  the  ordinary 
cardiac  rhythm  by  premature  contractions  followed  by  a  compensatory 
pause  are  not  uncommon  in  healthy  persons.  In  the  absence  of  all 
other  evidence  of  cardio-vascular  disease,  they  have  no  known  signifi- 
cance and  may  continue  throughout  life.  They  may  also  accompany 
various  types  of  heart  disease.  Many  of  them  represent  very  inefficient 
ventricular  contractions  and  are  not  transmitted  to  the  wrist.  This 
fact  together  with  the  compensatory  pause  and  the  presence  of  normal 
beats  before  and  after  them,  makes  them  recognizable  in  most  cases 
(see  also  p.  1 18). 

3.  If  we  leave  on  one  side  diseases  of  the  heart  itself,  pathological 
arrhythmia  is  most  frequently  seen  in  persons  who  have  used  tobacco  or 
tea  to  excess,  or  in  dyspepsia.  In  these  conditions  it  is  often  combined 
with  palpitation  and  becomes  thereby  very  distressing  to  the  patient. 
In  connection  with  cardiac  disease  the  following  types  of  arrhythmia 
may  be  distinguished : 

(a)  Paradoxical  Pulse. — Any  cause  which  leads  to  weakening  of 
the  heart's  action  may  occasionally  be  associated  with  paradoxical 
pulse.  Fibrous  pericarditis  has  been  supposed  to  be  frequently 
associated  with  this  type  of  arrhythmia,  but  if  so  it  is  by  no  means  its 
only  cause. 

(&)  The  bigeminal  pulse  is  seen  most  frequently  in  cases  of  uncom- 
pensated heart  disease  (particularly  mitral  stenosis)  after  the  adminis- 
tration of  digitalis.  Every  other  beat  is  weak  or  abortive  and  is  suc- 
ceeded by  an  unusually  long  pause.  Sometimes  every  third  beat  is  of 
the  abortive  type,  or  an  unusually  long  interval  may  divide  the  heart- 
beats into  groups  of  three  ("  trigeminal  pulse"). 

(c)  Delirium  cordis  or  absolute  irregularity  is  a  term  used  to  express 
great  irregularity  and  rapidity  of  the  heart-beats  which  cannot  be 
reduced  to  a  single  type  or  rhythm.  It  is  seen  in  the  gravest  stages 
of  uncompensated  heart  disease  from  any  cause  and  is  associated  with 
auricular  fibrillation.     See  above,  p.  116. 

Palpitation. 

Best  defined  as  an  "irregular  or  forcible  heart  action  perceptible 
to  the  individual."     The  essential  point  is  that  the  individual  becomes 


250  PHYSICAL  DIAGNOSIS 

conscious  of  each  beat  of  his  heart,  whether  or  no  the  heart  action  is 
in  any  way  abnormal. 

(a)  In  irritable  conditions  of  the  nervous  system,  such  as  occur 
at  puberty,  at  climacteric,  or  in  neurasthenic  persons,  palpitation 
may  be  very  distressing.  Temporary  disturbances,  such  as  fright, 
may  produce  a  similar  and  more  or  less  lasting  effect. 

(6)  The  effect  of  high  altitudes,  or  of  even  a  moderate  eleva- 
tion (1,500  feet)  is  sufficient  to  produce  in  many  healthy  persons  a 
quickening  and  strengthening  of  the  heart's  action,  so  that  sleep 
may  be  prevented.  After  a  few  nights  this  condition  usually  passes 
off,  provided  the  heart  is  sound. 

(c)  Abuse  of  tobacco  and  tea  have  a  similar  effect. 

(d)  Heart  block,  complete  or  partial  (see  above,  p  113). 

{e)  Gallop  rhythm  is  not  strictly  an  arrhythmia  but  an  auscultatory 
anomaly.     It  is  described  on  p.  176. 

Auscultation  of  a  palpitating  heart  shows  nothing  more  than 
unusually  loud  and  ringing  heart  sounds,  but  since  palpitation  is 
often  associated  with  arrhythmia  of  one  or  another  type  we  must  be 
careful  to  exclude  the  palpitation  symptomatic  of  acute  dilatation 
of  the  heart,  such  as  may  occur  in  debilitated  persons  after  violent 
or  unusual  exertion.  In  this  condition  the  area  of  cardiac  dulness 
is  increased  and  dyspnoea  upon  slight  exertion  becomes  marked.  It 
goes  without  saying  that  in  almost  any  case  of  organic  disease  of  the 
heart  palpitation  may  be  a  very  marked  and  distressing  symptom. 

Congenital  Heart  Disease. 

From  the  time  of  birth  it  is  noticed  in  some  cases  that  the  child 
is  markedly  cyanosed,  hence  the  term  "blue  baby."  Dyspnoea  is 
often,  though  not  always,  present,  and  may  interfere  with  sucking. 
The  cyanosis,  if  present,  is  practically  sufficient  in  itself  for  the 
diagnosis,  though  incomplete  expansion  of  the  lungs  may  simulate  it. 

Among  congenital  diseases  of  the  heart  the  commonest  and  the 
most  important  (because  it  is  less  likely  than  any  of  the  others  to  prove 
immediately  fatal)  is : 

I.  Pulmonary  Stenosis. 

This  lesion  is  usually  the  result  of  foetal  endocarditis,  and  is  often 
associated  with  malformations  and  defects,  such  as  patency  of  the 
foramen  ovale  and  persistence  of  the  ductus  arteriosus.  The  physical 
signs  of  pulmonary  stenosis  are: 


CONGENITAL  HEART  DISEASE  251 

(a)  A  palpable  systolic  thrill  most  distinct  in  the  pulmonary  area. 

(b)  A  loud  systolic  murmur  (often  rough  or  musical)  heard  best  in 
the  same  region,  but  transmitted  to  all  parts  of  the  chest. 

(c)  A  weak  or  absent  pulmonic  second  sound. 

(d)  An  increased  area  of  cardiac  dulness  corresponding  to  the  right 
ventricle. 

Unlike  most  other  varieties  of  congenital  heart  disease,  pulmonary 
stenosis  is  compatible  with  life  for  many  years,  and  "blue  babies" 
with  this  lesion  may  grow  up  and  enjoy  good  health,  although  usually 
subject  to  pulmonary  disorders  (pneumonia  or  tuberculosis).  For  a 
discussion  of  the  differential  diagnosis  of  this  lesion,  see  above,  p.  238. 

2.  Defects  in  the  Auricular  or  Ventricular  Septum. 

The  loud  systolic  murmur  produced  by  the  rush  of  blood  through  an 
opening  between  the  auricles  or  ventricles  is  heard,  as  a  rule,  over  the 
whole  precordia.  Its  point  of  maximum  intensity  differs  in  different 
cases,  but  is  hardly  ever  near  the  apex  of  the  heart.  The  most  im- 
portant diagnostic  point  (which  however  cannot  be  relied  upon)  is  the 
absence  of  a  palpable  thrill.  With  almost  every  other  form  of  con- 
genital heart  disease  in  which  a  loud  murmur  is  audible,  there  is  a 
thrill  as  well,  and  even  in  septum  defects  a  thrill  does  sometimes  occur, 
especially  if  the  auricular  septum  is  at  fault ;  but  thrills  are  nevertheless 
rarer  in  this  than  in  most  other  congenital  lesions.  Hypertrophy  of 
both  ventricles  may  be  present,  but  is  seldom  marked  in  uncomplicated 
cases. 

{Patency  of  the  foramen  ovale,  if  unassociated  with  other  defects, 
does  not  usually  produce  any  murmur  or  other  signs  by  which  it  can 
be  recognized  during  life,  and  causes  no  symptoms  of  any  kind.) 

3.  Persistence  of  the  Ductus  Arteriosus. 

The  most  characteristic  sign  is  a  loud,  vibratory  systolic  murmur 
with  its  greatest  intensity  at  the  base  of  the  heart  and  unassociated  with 
hypertrophy  of  either  ventricle.  If  complicated  with  stenosis  at  or  close 
above  the  pulmonary  valves,  persistence  of  the  ductus  arteriosus 
cannot  be  diagnosed,  as  the  murmur  produced  by  it  cannot  with 
certainty  be  distinguished  from  that  of  the  pulmonary  stenosis,  and 
the  presence  of  hypertrophy  of  the  right  ventricle  deprives  us  of  the 
one  relatively  characteristic  mark  of  a  patent  arterial  duct. 

Gibson  considers  that  a  murmur  persisting  through  systole  and  into 


252  PHYSICAL  DIAGNOSIS 

diastole  is  diagnostic  of  an  open  arterial  duct,  but  this  supposition  is 
not  borne  out  in  all  cases  by  post-mortem  evidence. 

The  signs  produced  by  the  other  varieties  of  congenital  heart 
disease,  such  as  aortic  stenosis  and  tricuspid  or  mitral  lesions,  do  not 
differ  materially  from  those  characterizing  those  lesions  in  adults. 
Excluding  these,  we  may  summarize  the  signs  of  the  other  lesions  as 
follows : 

(a)  Practically  all  cases  of  congenital  heart  disease,  which  produce 
any  physical  signs  beyond  cyanosis  and  dyspnoea,  manifest  themselves 
by  a  loud  systolic  murmur  heard  all  over  the  precordia  and  often 
throughout  the  chest.  Its  maximum  intensity  is  usually  at  or  near 
the  base  of  the  heart. 

(b)  If  there  is  no  thrill  and  no  hypertrophy,  the  lesion  is  probably  a 
defect  in  the  ventricular  septum. 

(c)  If  there  is  a  thrill  but  no  hypertrophy,  the  lesion  is  probably  a 
patent  ductus  arteriosus. 

{d)  If  there  is  a  thrill  and  hypertrophy  of  the  right  ventricle,  the 
lesion  is  probably  pulmonic  stenosis,  especially  if  the  pulmonic  second 
sound  is  feeble. 


CHAPTER  XIII. 
DISEASES  OF  THE  PERICARDIUM. 

I.  Pericarditis. 

Three  forms  may  be  recognized  clinically: 
(i)  Plastic,  dry,  or  fibrinous  pericarditis. 

(2)  Pericarditis  with  effusion  (serous  or  purulent). 

(3)  Pericardial  adhesions  or  adherent  pericardium. 

Fibrinous  pericarditis  may  be  fully  developed  without  giving  rise 
to  any  physical  signs  that  can  be  appreciated  during  life.  In  several 
cases  of  pneumonia  in  which  I  suspected  that  pericarditis  might  be 
present,  I  have  listened  most  carefully  for  evidences  of  the  disease 
and  been  unable  to  discover  any;  yet  at  autopsy  it  was  found  fully 
developed — the  typical  shaggy  heart.  We  have  every  reason  to 
believe,  therefore,  that  pericarditis  is  frequently  present  but  unrecog- 
nized, especially  in  pneumonia  and  in  the  rheumatic  attacks  of 
children.  On  the  other  hand,  it  may  give  rise  to  very  marked  signs 
which  are  the  result  of  — 

(a)  The  rubbing  of  the  roughened  pericardial  surfaces  against 
one  another  when  set  in  motion  by  the  cardiac  contractions. 

(6)   The  presence  of  fluid  in  the  pericardial  sac. 

(c)  The  interference  with  cardiac  contractions  brought  about  by 
obliteration  of  the  pericardial  sac  together  with  the  results  of  adhesions 
between  the  pericardium  and  the  surrounding  structures. 

(i)   Dry  or  Fibrinous  Pericarditis. 

The  diagnosis  rests  upon  a  single  physical  sign  —  "pericardial 
friction'' — which  is  usually  to  be  appreciated  by  auscultation  alone, 
but  may  occasionally  be  felt  as  well.  Characteristic  pericardial  friction 
is  a  rough,  irregular,  grating  or  shuffling  sound  which  occurs  irregu- 
larly and  interruptedly  during  the  larger  part  of  each  cardiac  cycle. 
It  is  almost  never  accurately  synchronous  either  with  systole  or  diastole, 
but  overlaps  the  cardiac  sounds,  and  encroaches  upon  the  pauses  in  the 
heart  cycle.  It  is  seldom  exactly  the  same  in  any  two  successive 
cardiac  cycles  and  differs  thereby  from  sounds  produced  within  the 

253 


254  PHYSICAL  DIAGNOSIS 

heart  itself.  Pericardial  friction  seems  very  near  to  the  ear  and  may 
often  be  increased  by  pressure  with  the  stethoscope ;  it  is  not  materially 
influenced  by  the  respiratory  movements. 

It  is  best  heard  in  the  majority  of  cases  in  the  position  shown 
in  Fig.  169;  that  is,  over  that  portion  of  the  heart  which  lies  nearest 
to  the  chest  wall  and  is  not  covered  by  the  margins  of  the  lungs; 
but  not  infrequently  it  may  be  heard  at  the  base  of  the  heart  along  the 
right  sternal  margin  or  over  the  whole  precordial  region.     The  sounds 


.  Pericardial  friction. 


Fig.  169. — Showing  Most  Frequent  Site  of  Audible  Pericardial  Friction. 

are  fainter  if  the  patient  lies  on  the  right  side,  and  sometimes  intensified 
if,  while  sitting  or  standing,  he  leans  forward  and  toward  the  left,  so  as 
to  bring  the  heart  into  closer  apposition  with  the  chest  wall. 

Pericardial  friction  sounds  often  change  rapidly  from  hour  to  hour, 
and  may  disappear  and  reappear  in  the  course  of  a  day. 

In  rare  cases  the  friction  may  occur  only  during  systole  or  only 
during  diastole.  In  such  cases  the  diagnosis  between  pericardial 
and  intracardial  sounds  may  be  very  difficult. 

Differential  Diagnosis. 
(a)   Pleuro- pericardial  Friction. 

Fibrinous  inflammation  affecting  that  part  of  the  pleura  which 
overlaps  the  heart  may  give  rise  to  sounds  altogether  indistinguishable 
from  those  of  true  pericardial  friction  when  the  inflamed  pleural 
surfaces  are  made  to  grate  against  one  another  by  the  movements  of 


DISEASES  OF  THE  PERICARDIUM  255 

the  heart.  Such  sounds  are  sometimes  increased  in  intensity  during 
forced  respiration  and  disappear  at  the  end  of  expiration,  while  true 
pericardial  friction  is  usually  best  heard  if  the  breath  is  held  at  the 
end  of  expiration.  If  a  friction  sound  heard  in  the  pericardial  region 
ceases  altogether  when  the  breath  is  held,  we  may  be  sure  that  it  is 
produced  in  the  pleura  and  not  in  the  pericardium,  but  in  many 
cases  the  diagnosis  cannot  be  made  correctly. 

(b)   Intracardiac  Murmurs. 

From  murmurs  due  to  valvular  disease  of  the  heart,  pericardial 
friction  can  usually  be  distinguished  by  the  fact  that  the  sounds  to 
which  it  gives  rise  do  not  accurately  correspond  either  with  systole 
or  diastole,  and  do  not  occupy  constantly  any  one  portion  of  either 
of  these  periods.  Cardiac  murmurs  are  more  regular,  seem  less 
superficial,  and  vary  less  with  position  and  from  hour  to  hour.  Pres- 
sure with  the  stethoscope  does  not  increase  so  strikingly  the  intensity 
of  intracardiac  murmurs.  When  endocarditis  and  pericarditis  occur 
simultaneously,  it  may  be  very  difficult  to  distinguish  the  two  sets 
of  sounds  thus  produced.  The  pericardial  friction  is  usually  recognized 
with  comparatively  little  difficulty,  but  it  is  hard  to  make  sure  whether 
in  addition  we  hear  endocardial  murmurs  as  well. 

(2)  Pericardial  Effusion. 

Following  the  fibrinous  exudation,  which  roughens  the  pericar- 
dial surface  and  produces  the  friction  sounds  just  described,  serum 
may  accumulate  in  the  pericardial  sac.  Its  quantity  may  exceed  but 
slightly  the  amount  of  fluid  normally  present  in  the  pericardium,  or 
may  be  so  great  as  to  embarrass  the  cardiac  movements  and  finally 
to  arrest  them  altogether.  In  chronic  (usually  tuberculous)  cases, 
the  pericardium  may  become  stretched  so  as  to  hold  a  quart  or  more 
without  seriously  interfering  with  the  heart's  action,  while  a  much 
smaller  quantity,  if  effused  so  rapidly  that  the  pericardium  has  no 
time  to  accommodate  itself  by  stretching,  will  prove  rapidly  fatal. 

Hydropericardium  denotes  a  dropsy  of  the  pericardium  occurring 
by  transudation  as  part  of  a  general  dropsy  in  cases  of  renal  disease  or 
cardial  weakness.  The  physical  signs  to  which  it  gives  rise  do  not 
differ  from  those  of  an  inflammatory  effusion,  and,  accordingly,  all 
that  is  said  of  the  latter  in  the  following  section  may  be  taken  as 
equally  an  account  of  the  signs  of  hydropericardium. 


256 


PHYSICAL  DIAGNOSIS 


Haemopericardium,  or  blood  in  the  pericardial  sac,  due  to  stabs  or 
to  ruptures  of  the  heart,  is  usually  so  rapidly  fatal  that  no  physical 
sio;ns  are  recognizable. 


Fig.  170. — Pericardial  Effusion,  Cardio-hepatic  Angle  obtuse.     (From  v.  Ziemssen's  Atlas.) 


Physical  Signs  of  Pericardial  Effusion. 

In  most  cases  a  pericardial  friction  rub  has  been  observed  prior  to 
the  time  of  the  fluid  accumulation.  The  presence  of  fluid  in  the 
pericardial  sac  is  shown  chiefly  in  three  ways : 

(i)  By  percussion,  which  demonstrates  an  area  of  dulness  more  or 
less  characteristic  (see  below). 

(2)  By  auscultation,  which  may  reveal  an  unexpected  feebleness  in 
the  heart  sounds  when  compared  with  the  power  shown  in  the  radial 
pulse. 

(3)  By  the  signs  and  symptoms  of  pressure  exerted  by  the  peri- 
cardial effusion  upon  surrounding  structures. 

Bulging  of  the  precordia  is  occasionally  to  be  seen  in  children;  in 
adults  we  sometimes  observe  a  flattening  of  the  interspaces  just  to  the 
right  of  the  sternum  between  the  third  and  sixth  ribs. 

(i)  The  Area  of  Percussion  Dulness. — The  extent  of  the  dull  area 
depends  not  only  on  the  size  of  the  effusion  and  the  position  of  the 


DISEASES  OF  THE  PERICARDIUM  257 

patient,  but  also  on  the  amount  of  "give"  in  the  pericardium  and  in 
the  lungs,  as  well  as  on  the  size  of  the  lingula  pulmonalis.  Allowing 
for  these  uncertain  factors,  we  may  say:  (a)  One  of  the  most  charac- 
teristic points  is  the  unusuaP  extension  of  the  percussion  dulness  a 
considerable  distance  to  the  left  of  the  maximum  cardiac  impulse. 
(b)  Next  to  this,  it  is  important  to  notice  a  change  in  the  angle  made 
by  the  junction  of  the  horizontal  line  corresponding  to  the  upper  limit 
of  hepatic  dulness  and  the  nearly  perpendicular  line  corresponding  to 
the  right  border  of  the  heart.  In  health  this  cardio-hepatic  angle  is 
approximately  a  right  angle;  in  pericardial  effusion  it  is  much  more 
obtuse  (see  Fig.  171).     Rotch  has  called  attention  to  the  importance 


__. Tympany. 


\^,-   Dulness. 


Cardiac  impulse. 


Liver  dulness.  ^ 


Fig.  17 1. ^Percussion  Dulness  in  Pericardial  Effusion,  with  Tympanitic  Resonance  Under 

the  Left  Clavicle. 


of  dulness  in  the  fifth  right  intercostal  space  as  a  sign  of  pericardial 
effusion,  but  a  similar  dulness  may  be  produced  by  enlargement  of  the 
liver. 

Except  for  the  two  points  mentioned  above  (the  unusual  extension 
of  the  dulness  to  the  left  of  the  cardiac  impulse  and  the  blunting  of  the 
cardio-hepatic  angle),  there  seems  to  me  to  be  nothing  characteristic 
about  the  area  of  dulness  produced  by  pericardial  effusion.  The 
"pear-shaped"  or  triangular  area  of  percussion  dulness  mentioned  by 
many  writers  has  not  been  present  in  cases  which  have  come  under 
my  observation. 

^  In  health  the  cardiac  dulness  extends  about  f  of  an  inch  beyond  the  maximum  cardiac 
impulse,  but  in  pericardial  effusion  the  difference  is  greater. 
17 


258  PHYSICAL  DIAGNOSIS 

In  some  cases  the  area  of  dulness  may  be  modified  by  change  in  the 
patient's  position.  After  marking  out  the  area  of  percussion  dulness 
with  the  patient  in  the  upright  position,  let  him  lie  upon  his  right  side. 
The  right  border  of  the  area  of  dulness  will  sometimes  move  consider- 
ably farther  to  the  right.  A  dilated  heart  can  be  made  to  shift  in  a 
similar  way,  but  to  a  lesser  extent.  Comparatively  little  change  takes 
place  if  the  patient  lies  on  his  left  side,  and  no  important  information 
is  elicited  by  placing  him  flat  on  his  back  or  by  getting  him  to  lean 
forward. 

Unfortunately,  it  is  only  with  moderate-sized  effusions  occurring 
in  a  pericardial  sac  free  from  adhesions  to  the  surrounding  parts  that 
this  shifting  can  be  made  out.  Large  effusions  may  not  shift  appre- 
ciably, and  less  than  150  c.c.  of  fluid  probably  cannot  be  recognized  by 
this  or  by  any  other  method.  But  with  large  effusions  the  lateral 
extension  of  the  area  of  dulness  may  be  so  great  as  to  be  almost  dis- 
tinctive in  itself,  i.e.,  from  the  middle  of  the  left  axilla  nearly  to  the 
right  nipple. 

(2)  Feebleness  of  the  heart  sounds  and  of  the  apex  impulse  is  of 
diagnostic  importance  only  when  it  gradually  takes  the  place  of  the 
normal  phenomena  as  one  watches  the  heart  from  day  to  day.  Under 
these  conditions  they  have  some  confirmatory  value  in  the  diagnosis 
of  pericardial  effusion. 

(3)  Tubular  breathing  with  dulness,  increased  voice  sounds  and 
tactile  fremitus  can  often  be  heard  near  the  angle  of  the  left  scapula. 
This  is  usually  a  result  of  compression  of  the  lung,  but  a  patch  of 
pneumonia  or  a  pleural  effusion  may  be  present  and  produce  almost 
identical  signs. 

A  patch  of  tympanitic  resonance  is  often  to  be  found  below  the 
left  clavicle,  due  no  doubt  to  relaxation  of  the  lung. 

Pressure  exerted  by  the  pericardial  exudation  upon  surrounding 
structures  may  also  give  rise  to  dyspnoea,  especially  of  a  paroxysmal 
type,  to  dysphagia,  to  aphonia,  and  to  an  irritating  cough.  The 
"paradoxical  pulse,"  small  and  feeble  during  inspiration,  is  occasion- 
ally to  be  seen,  but  is  by  no  means  peculiar  to  this  condition  and  has 
no  considerable  diagnostic  importance. 

(4)  Inspection  and  palpation  usually  help  us  very  little,  but  two 
points  are  occasionally  demonstrable  by  these  methods : 

(a)  A  smoothing  out  of  the  intercostal  depression  in  the  precordial 
region,  especially  near  the  right  border  of  the  sternum  between  the 
third  and  the  sixth  ribs. 

(6)   A  progressive  diminution  of  the  intensity  of  the  apex  impulse 


DISEASES  OF  THE  PERICARDIUM  259 

until  it  may  be  altogether  lost.  If  this  change  occurs  while  the 
patient  is  under  observation,  and  especially  if  the  apex  impulse 
reappears  or  becomes  more  distinct  when  the  patient  lies  on  the  right 
side,  it  is  of  considerable  diagnostic  value.  In  conditions  other  than 
pericardial  effusion,  the  apex  impulse  becomes  less  visible  in  the  right- 
sided  decubitus. 

Differential  Diagnosis. 

(i)  Our  chief  difficulty  is  to  distinguish  the  disease  from  hyper- 
trophy and  dilatation  of  the  heart.  In  the  latter,  which  often  com- 
plicates acute  articular  rheumatism  with  or  without  plastic  pericarditis, 
the  apex  impulse  is  often  very  indistinct  to  sight  and  touch  as  in 
pericardial  effusion.  But  the  area  of  dulness  is  less  likely  to  extend 
beyond  the  apex  impulse  to  the  left,  or  to  modify  the  cardio-hepatic 
angle,  or  to  shift,  when  the  patient  lies  on  the  right  side.  Pressure 
symptoms  are  less  marked  and  there  are  usually  no  areas  of  broncho- 
vesicular  breathing  with  tympanitic  resonance  under  the  left  clavicle 
or  in  the  back.  Yet  not  infrequently  these  differentiae  do  not  serve 
us,  and  the  diagnosis  can  be  made  only  by  puncture. 

(2)  I  have  twice  known  cases  of  encapsulated  or  interlobar  em- 
pyema to  be  mistaken  for  pericardial  effusion.  In  one  case  a  needle 
introduced  in  the  fifth  left  intercostal  space  below  the  nipple  drew 
pus  from  what  turned  out  later  to  be  a  localized  purulent  pleurisy, 
but  the  diagnosis  was  not  made  until  a  rib  had  been  removed  and  the 
region  thoroughly  explored.  It  is  not  rare  for  pleuritic  effusions  to 
gather  first  in  this  situation,  viz.,  just  outside  the  apex  impulse  in  the 
left  axilla. 

Such  effusions  may  gravitate  very  slowly  to  the  bottom  of  the 
pleural  cavity  or  may  become  encapsulated  and  remain  in  their 
original  and  very  deceptive  position.  In  such  cases  the  signs  of 
compression  of  the  left  lung  are  similar  to  those  produced  by  a  peri- 
cardial effusion,  and  the  results  of  punctures  may  be  equivocal  as 
in  the  case  just  mentioned.  If  there  is  any  dulness,  even  a  very  narrow 
zone,  in  the  left  axilla  between  the  fifth  and  eighth  ribs,  though  there  be 
none   in  the  back,  the  likelihood  of  empyema  should  be  suggested. 

As  between  pleuritic  and  pericardial  effusion  the  presence  of  a 
good  pulse  and  the  absence  of  marked  dyspnoea  favors  the  former. 
In  the  two  cases  above  referred  to  in  which  interlobar  empyema  was 
mistaken  for  pericarditis,  the  general  condition  of  the  patient  struck 
me  at  the  time  as  surprisingly  good  for  pericarditis. 


260  PHYSICAL  DIAGNOSIS 

If  both  pleurisy  and  pericarditis  are  present,  the  area  of  pericardial 
dulness  is  not  characteristic  until  the  pleuritic  fluid  has  been  drawn 
off.  The  persistence  of  dulness  in  the  cardio-hepatic  angle  and  beyond 
the  apex  beat  after  a  left  pleurisy  has  been  emptied  by  tapping,  and 
after  the  heart  has  had  time  to  return  to  its  normal  position,  should 
make  us  suspect  a  pericardial  eifusion. 

Despite  the  utmost  care  and  thoroughness  in  physical  examination, 
many  cases  of  pericardial  effusion  go  unrecognized,  especially  in 
infants,  in  elderly  persons,  or  when  the  lung  borders  are  adherent  to 
the  pericardium  or  to  the  chest  wall. 

In  the  rheumatic  attacks  of  children,  it  should  be  remembered  that 
pericarditis  is  even  more  common  than  endocarditis. 

Adherent  Pericadium. 

In  the  majority  of  cases  the  diagnosis  cannot  be  made  during 
life,  unless  the  pericardium  is  adherent,  not  only  to  the  heart,  but  to 
the  walls  of  the  chest  as  well.  When  this  combination  of  pericarditis 
with  chronic  mediastinitis  is  present,  the  diagnosis  may  be  suggested 
by 

(a)  A  systolic  retraction  of  the  chest  wall  in  the  region  of  the  apex 
impulse,  at  the  base  of  the  left  axilla  and  in  the  region  of  the  eleventh 
and  twelfth  ribs  in  the  left  back  (Broadbent's  sign).  Such  retraction 
is  more  marked  during  a  deep  inspiration.  (It  should  be  remembered 
that  systolic  retraction  of  the  interspaces  in  the  vicinity  of  the  apex 
is  very  commonly  seen  in  cases  of  cardiac  hypertrophy  from  any  cause, 
owing  to  the  negative  pressure  produced  within  the  chest  by  the 
contraction  of  a  powerful  heart.)  A  quick  rebound  of  the  cardiac 
apex  at  the  time  of  diastole  (the  diastolic  shock)  is  said  to  be  character- 
istic of  pericardial  adhesions,  but  is  often  absent. 

(&)  Collapse  of  the  cervical  veins  during  diastole  has  been  noticed 
by  Friedreich,  and  the  paradoxical  pulse,  above  described,  is  said  to 
be  more  marked  in  adherent  pericardium  than  in  any  other  known 
condition.     Most  recent  writers,  however,  place  no  reliance  upon  it. 

(c)  Broadbent  considers  that  the  absence  of  any  shift  in  the 
position  of  the  apex  beat  with  respiration  or  change  of  patient's 
position,  is  an  important  point  in  favor  of  mediastino-pericarditis. 
In  health  and  in  valvular  or  parietal  disease  of  the  heart,  the  apex 
beat  will  swing  from  one  to  two  inches  to  the  left  when  the  patient 
lies  on  his  left  side,  and  the  descent  of  the  diaphragm  during  full 
nspiration  lowers  the  position  of  the  cardiac  impulse  considerably. 


DISEASES  OF  THE  PERICARDIUM 


261 


{d)  The  presence  of  hypertrophy  or  dilatation  affecting  especially 
the  right  side  of  the  heart,  and  not  accounted  for  by  the  existence 
of  any  disease  of  the  arteries,  the  cardiac  valves,  the  lung,  or  of  the 
kidney,  should  make  us  suspect  pericardial  and  mediastinal  adhesions. 
Such  adhesions  embarrass  especially  the  right  ventricle,  because  it  is 
the  right  ventricle  far  more  than  the  left  which  becomes  attached  to 
the  chest  wall.     The  left  ventricle  is  more  nearly  free. 

(e)  Since  the  space  enclosed  by  the  divergent  costal  cartilage 
just  below  the  ensiform  is  but  loosely  associated  with  the  central  ten- 
don of  the  diaphragm,   Broadbent  looks  especially  at  this  point  for 


Fig.   172. — Adherent  Pericardium,  Ascites. 


evidence  of  mediastinal  or  pericardial  adhesions,  the  effect  of  which 
is  to  arrest  completely  the  slight  respiratory  movements  of  this  part 
of  the  abdominal  wall. 

(/)  Adherent  pericardium,  occurring  as  a  part  of  a  widespread  chain 
of  fibrous  processes  involving  the  pleura,  the  mediastinum,  and  the 
peritoneum,  may  give  rise  in  young  persons  to  a  train  of  symptoms 
and  signs  suggesting  cirrhosis  of  the  liver.  Ascites  collects,  the  liver 
is  enlarged,  yet  there  are  no  signs  in  the  heart,  kidneys,  or  blood 
sufficient  to  explain  the  condition.  In  any  such  case  adherent  peri- 
cardium should  be  considered.  Fig.  172  shows  the  appearance  in 
cases  of  this  kind  in  which  the  diagnosis  was  verified  by  autopsy. 


262     '  PHYSICAL  DIAGNOSIS 

Summary. 

The  diagnosis  of  adherent  pericardium  with  chronic  mediastini- 
tis  is  suggested  by 

(a)  SystoHc  retraction  of  the  lower  intercostal  spaces  in  the  left 
axilla  and  in  the  left  back,  followed  by  a  diastolic  rebound. 

(6)  The  absence  of  any  change  in  the  position  of  the  apex  impulse 
with  respiration  or  change  of  position. 

(c)  The  presence  of  hypertrophy  and  dilatation  of  one  or  both 
ventricles  without  obvious  cause. 

(d)  The  absence  of  any  respiratory  excursion  of  the  abdominal 
wall  at  the  costal  angle. 

(e)  The  presence  of  signs  like  those  of  hepatic  cirrhosis  in  a  young 
person  and  without  any  obvious  cause. 


CHAPTER  XIV. 

THORACIC  ANEURISM. 

Aneurism  of  the  Thoracic  Aorta. 

For  clinical  purposes  thoracic  aneurisms  may  be  divided  into  the 
diffuse  and  the  saccular.  Saccular  aneurisms  of  the  ascending  or 
descending  portion  of  the  arch  of  the  aorta  are  apt  to  penetrate  the 
chest  wall,  while  aneurism  of  the  transverse  aorta  or  diffuse  dilatations 
of  the  whole  aortic  arch  are  more  likely  to  extend  within  the  chest 
without  eroding  the  thoracic  bones.  Practically  any  aneurism  which 
penetrates  the  thoracic  bones  may  be  inferred  to  be  saccular,  but  if 
no  such  penetration  takes  place,  it  may  be  impossible  to  make  out 
whether  the  dilatation  is  diffuse  or  circumscribed.     I  shall  consider ; 

I.  The  signs  of  the  presence  of  aneurism. 

II.  The  evidences  of  its  seat. 

Abnormal  Pulsation. 

Inspection  and  palpation  give  us  most  of  the  important  information 
in  the  diagnosis  of  aneurism.  The  patient  should  be  placed  in  the 
position  shown  in  Fig.  170,  so  that  the  light  will  strike  obliquely  across 
the  surface  of  the  chest,  and  the  observer  should  be  so  placed  that  his 
eyes  are  as  nearly  as  possible  at  the  level  at  that  part  of  the  chest  at 
which  he  expects  to  see  pulsation. 

In  the  majority  of  cases  of  aneurism  some  abnormal  pulsation  may 
be  made  out  either  to  the  right  of  the  sternum  in  front  or  in  the  region 
of  the  left  scapula  behind.  If  the  aneurism  is  large,  a  considerable 
area  of  the  chest  wall  may  be  lifted  with  each  beat  of  the  heart;  with 
smaller  growths  the  pulsating  area  may  be  small  and  sharply  cir- 
cumscribed. Not  infrequently  an  abnormal  pulsation  at  the  sternal 
notch  or  in  the  neck  may  also  be  observed.  Other  causes  of  ab- 
normal pulsations  in  the  chest,  such  as  dislocation  or  uncovering 
of  the  heart,  must  of  course  be  excluded. 

Palpation  controls  the  results  of  inspection,  but  at  times  a  pulsation 
may  be  seen  better  than  felt;  at  others  may  be  felt  better  than  seen. 

Tumor. 

If  the  aneurism  involves  the  ascending  portion  of  the  aortic  arch, 
it  is  likely  sooner  or  later  to  erode  the  right  margin  of  the  sternum  and 
the  adjacent  parts  of  the  second  or  third  costal  cartilages  and  appear 

263 


264 


PHYSICAL  DIAGNOSIS 


externally  as  a  round  swelling  in  which  a  systolic  pulsation  is  to 
be  seen  and  felt.  This  pulsation  is  in  some  cases  distinctly  expansile 
in  character,  and  differs  in  this  respect  from  the  up-and-down  motion 
which  may  be  communicated  to  a  tumor  of  the  chest  wall  by  the  beat- 
ing of  a  normal  aorta.  The  tumor  is  usually  firm,  rarely  soft,  and 
may  be  as  hard  as  any  variety  of  malignant  new  growth.  Occa- 
sionally the  thickness  of  the  lamellated  clot  within  it  is  so  great 
that  no  pulsations  are  transmitted  to  the  surface. 

Thrill. 
Whether  the  aneurism  penetrates  the  chest  or  not,  it  is  often  possi- 
ble to  feel  over  it  a  vibrating  thrill,  systolic  in  time.     If  the  layer  of 
lamellated  clot  in  the  sac  is  very  thick,  the  thrill  is  less  apt  to  be  felt. 


Fig.   173. — Position  When  Looking  for  Slight  Aneurismal  Pulsation. 


Diastolic  Shock. 

More  important  in  diagnosis  is  a  diastolic  shock  or  tap  which  is 
appreciated  by  laying  the  palm  of  the  hand  lightly  over  the  affected 
area.  This  diastolic  shock  is  due  to  the  recoil  of  the  blood  in  the 
dilated  aorta,  and  is  one  of  the  important  and  characteristic  signs  in 
aneurism.  As  the  wall  of  the  sac  becomes  weaker,  the  intensity  of 
this  shock  diminishes.  This  diastolic  shock  may  be  appreciated  over 
the  trachea  also,  and  is  thought  by  some  to  have  even  more  signifi- 
cance when  felt  in  this  situation. 

Of  special  importance  in  aneurism  of  the  transverse  arch  is  the  sign 
known  as  the  tracheal  tug.     The  arch  of  the  aorta  runs  over  the  left 


THORACIC  ANEURISM 


265 


primary  bronchus  in  such  a  way  that  when  the  aorta  is  dilated,  the 
bronchus  is  pressed  upon  with  each  expansile  pulsation  of  the  artery. 


Fig.  174. — Aneurismal  Tumor  (A).  The  arrow  B  points  to  a  gummatous  swelling 
near  the  ensiform  cartilage.  The  radiographic  appearances  of  this  case  are  shown  below 
(Fig.  177). 


Fig.  175. — Aneurism  Tumor  Perforating  the  Sternum  at  A.     At  B  there  is  a  gummatous 
mass.     (See  below,  Fig.  177,  a  radiograph  of  this  case). 

Tracheal  Tug. 

This  systolic  pressure  transmitted  to  the  trachea  produces  a  distinct 
downward  tug  upon  it  with  each  systole  of  the  heart.     The  tug  is  best 


266  PHYSICAL  DIAGNOSIS 

felt  by  making  the  patient  throw  back  his  head  so  as  to  put  the  trachea 
upon  a  stretch.  The  physician  then  stands  behind  him  and  gently 
presses  the  tips  of  the  fingers  of  both  hands  up  under  the  lower  border 
of  the  cricoid  cartilage.  In  feeling  thus  for  the  tracheal  tug  as  trans- 
mitted to  the  cricoid  cartilage  certain  precautions  must  be  observed : 

(a)  One  must  distinguish  the  tracheal  tug  from  a  simple  pulsation 
transmitted  to  the  superficial  tissues  by  the  vessels  underneath.  Such 
pulsation  makes  the  tissues  move  out  and  in  rather  than  up  and  down. 

(6)  A  tracheal  tug  felt  only  during  inspiration  has  no  pathological 
significance  and  is  frequently  present  in  health. 

While  preparing  to  try  for  the  tracheal  tug  we  may  notice  whether 
there  is  any  dislocation  of  the  trachea,  as  shown  by  the  displacement 
of  Adam's  apple.  Aphonia,  stridor,  cough,  dysphagia,  and  other 
symptoms  are  produced  by  pressure  on  gullet  and  windpipe.  Other 
signs  of  aneurism,  due  to  the  pressure  of  the  dilated  aorta  upon  the 
nerves  or  vessels  of  the  mediastinum,  are: 

(i)   Inequality  of  the  pupils. 

(2)  Inequality  of  the  radial  pulses. 

(3)  CEdema  and  cyanosis  of  one  arm  or  of  one  side  of  the  neck 
and  head. 

(4)  Pain  in  one  arm  from  the  pressure  of  an  aneurism  involving 
the  subclavian  artery  upon  the  brachial  plexus. 

(5)  Clubbing  of  the  fingers  of  one  hand  (rare). 

(6)  Prominence  of  one  eye  (rare). 

(7)  Flushing  or  sweating  of  one  side  of  the  face  (very  rare). 

Contraction  or  dilatation  of  the  pupil  is  due  to  a  paralytic  or  irrita- 
tive affection  of  the  sympathetic  nerves.  This  symptom  is  much 
commoner  than  the  other  effect  of  pressure  upon  the  sympathetic 
nerves;  namely,  flushing  or  sweating  of  one  side  of  the  face. 

In  comparing  the  pulses  in  the  two  radials  we  must  bear  in  mind 
the  possibility  of  a  congenital  difference  between  them,  due  to  a 
difference  either  in  the  size  of  the  arteries  or  in  their  position,  and  also 
that  a  tumor  pressing  on  the  subclavian  may  affect  the  pulse  exactly 
as  an  aneurism.  The  pulse  wave  upon  the  affected  side  (most  often 
the  left)  may  be  either  less  in  volume  or  later  in  time  than  the  wave  in 
the  other  radial  artery,  according  as  the  pulse  wave  is  actually  delayed 
in  the  aneurismal  sac  or  merely  diminished  by  it.  In  marked  cases  the 
pulse  upon  the  affected  side  may  be  nearly  or  quite  absent. 

Examination  of  the  heart  itself  may  show  some  dislocation  of  the 
organ  to  the  left  and  downward,  owing  to  the  direct  pressure  of  the 
aneurismal  sac,  but  no  enlargement. 


THORACIC  ANEURISM  267 

II.  Percussion. 

If  the  aneurism  is  deep-seated,  the  results  of  percussion  are  nega- 
tive. If,  on  the  other  hand,  it  be  situated  immediately  beneath  the 
sternum  on  close  under  the  thoracic  wall,  an  area  of  dulness,  not  present 
in  the  normal  chest,  may  be  mapped  out.  The  outlines  most  com- 
monly seen  in  such  cases  are  shown  in  Fig.  176.     When  the  aneurism 


Aneurismal  _  4  - 
dulness. 


L  -  Heart  dulness. 


Liver  dulness.' 


Fig.  176. — Diagram  of  Percussion  Dulness  in  Aortic  Aneurism. 


involves  the  descending  aorta,  an  area  of  dulness  may  be  found  in  the 
region  of  the  left  scapula  or  below  it,  and  pulsation  may  be  detected 
in  the  same  area. 

III.  Auscultation. 

The  signs  revealed  by  auscultation  are  not  of  much  diagnostic  value 
as  a  rule.  In  about  one-half  of  the  cases  of  sacculated  aneurism  there 
are  no  sounds  or  murmurs  to  be  heard  over  the  tumor.  In  other 
cases  a  systolic  murmur,  the  audible  counterpart  of  the  vibratile  thrill, 
may  be  heard  over  the  area  of  pulsation,  tumor,  or  dulness  correspond- 
ing to  the  aneurismal  sac.  This  systolic  murmur  may  be  due  to  many 
causes  other  than  aneurism,  and  has  nothing  characteristic  about  it.  A 
similar  systolic  sound  is  sometimes  heard  over  the  trachea  (Drum- 
mond's  sign)  or  in  the  mouth,  if  the  patient  closes  his  lips  around  the 
pectoral  extremity  of  the  stethoscope  (Sansom's  sign). 

A  loud,  low-pitched  diastolic  sound,  corresponding  to  the  palpable 
diastolic  shock,  is  generally  to  be  heard  in  the  aortic  region. 

If  a  portion  of  either  lung  is  directly  pressed  upon  by  the  aneurismal 


268 


PHYSICAL  DIAGNOSIS 


sac,  we  may  have  the  signs  of  condensation  of  the  lung  in  the  area 
pressed  upon  (sHght  dulness,  broncho-vesicular  breathing,  and 
exaggerated  voice  sounds).  If  one  of  the  primary  bronchi  fs  pressed 
upon,  as  occasionally  happens,  atelectasis  of  the  corresponding  lung 
may  be  manifested  by  the  usual  signs  (dulness,  absence  of  tactile 
fremitus  and  of  respiratory  and  vocal  sounds) . 

Since  aneurism  is  frequently  associated  with  regurgitation  at  the 
aortic  valve,  a  diastolic  murmur  is  not  infrequently  to  be  heard. 

If  the  aneurismal  sac  is  of  very  great  size,  the  pulse  wave  in  the 
femorals  may  be  obliterated,  as  happened  in  a  case  described  by  Osier. 

IV.  Radioscopy. 

With  the  fluoroscope  and  through  radiography  one  can  often 
make  out  a  shadow  corresponding  to  the  position  of  the  aneurism. 


From  the  front. 


From  behind. 


Fig.  177. — Radiograph  of  Case  whose  Photograph  is  Reproduced  as  Figs.  174  and  175. 
In  the  right-hand  cut  are  shown  the  appearances  seen  from  behind.  The  left-hand  cut, 
A,  A.  aneurismal  sac;  B,  heart  displaced;  C,  liver  (not  in  focus). 

The  position  of  the  shadow  is  best  explained  by  reference  to  Figs. 
177,  178,  179,  and  180. 


Sufnmary. 

The  most  important  signs  of  aneurism  are: 

1.  Abnormal  pulsation — visible  or  palpable 

2.  Tumor  over  which  a 

3.  Thrill  and  a 


THORACIC  ANEURISM 


269 


Diastolic  shock  may  be  felt. 

Tracheal  tug. 

Pressure  signs  (unequal  pulses,  pupils,  hoarseness,  pain,  etc.), 

Dulness  on  percussion  over  the  suspected  area. 

Loud,  low-pitched  aortic  second  sound. 

Systolic  murmur  (least  important  of  all). 


Fig.   178. — Aortic  Aneurism.     (From  v.  Ziemssen's  Atlas.) 

10.  Radioscopy  may  demonstrate  a  shadow  higher  up  than  that 
corresponding  to  the  heart  and  extending  beyond  that  produced  by 
the  sternum,  spinal  column,  and  great  vessels. 


Diagnosis  of  the  Seat  of  the  Lesion. 

(a)  Aneurism  of  the  ascending  arch  generally  approaches  or  pene- 
trates the  chest  wall  in  the  vicinity  of  the  second  right  intercostal  space 
near  the  sternum.  Previous  to  perforating  the  thoracic  parietes,  the 
growth  of  the  aneurism  may  give  rise  to  pain,  pulsation,  and  dulness 
and  thrill  in  this  region. 

(6)  Aneurism  of  the  transverse  arch  or  diffuse  dilatation  of  the 
aorta,  which  is  the  most  common  of  all  types  of  aortic  aneurism,  may 
not  give  rise  to  any  visible  pulsation  of  the  chest  wall,  and,  if  deep- 


270 


PHYSICAL  DIAGNOSIS 


seated,  need  not  produce  any  abnormal  dulness  on  percussion.  In 
such  cases  an  aneurism  is  to  be  recognized,  if  at  all,  by  evidences  of 
pressure  on  the  nerves  or  vessels  of  the  mediastinum  (cough,  aphonia, 
inequality  of  the  pupils,  tracheal  tug,  etc.) . 

(c)  Anetirism  of  the  descending  aorta  gives  rise  usually  to  severe 
and  persistent  pain  in  the  back,  which  raidates  along  the  intercostal 
nerves  or  downward.  Other  pressure  symptoms  are  not  marked,  but 
in  advanced  cases  an  area  of  abnormal  dulness  and  pulsation  may  be 
found  in  the  region  of  the  left  scapula  or  below  it. 


Fig.  179. — Aneurism  of  the  Aorta.     (Curschman.) 

(d)  If  the  innominate  artery  or  one  of  the  carotids  is  involved, 
we  usually  find  a  pulsating  lump  in  the  region  of  one  or  the  other 
claviculo-sternal  joint  or  at  the  root  of  the  neck,  and  the  trachea  may 
be  displaced  to  one  side.  This  form,  however,  is  distinctly  rare. 
The  violent  throbbing  and  dilated  carotid  of  aortic  leakage  is  often 
mistaken  for  it. 


Differential  Diagnosis. 

(a)  It  is  important  to  distinguish  the  diffuse  dilatation  of  the 
aortic  arch,  which  sooner  or  later  complicates  almost  every  case  of 
incompetency  of  the  aortic  valves,   from  saccular  aneurism  of  the 


THORACIC  ANEURISM 


271 


transverse  aorta.  Dulness  and  pulsation,  perhaps  with  systoHc  mur- 
mur and  thrill  in  the  second  and  third  right  interspaces  near  the 
sternum,  occur  in  many  cases  of  aortic  regurgitation,  but  though  the 
aorta  is  dilated,  its  coats  are  not  ruptured  and  it  never  breaks.  The 
absence  of  pressure  signs  (pain,  aphonia,  etc.)  and  the  shape  of  the 
ic-ray  shadow  distinguish  it  from  true  aneurism. 

(&)   Aneurism  is  not  infrequently  mistaken  for  aortic  stenosis,  in 
which  a  systolic  murmur  and  thrill,  similar  to  those  occurring  in  aneu- 


FiG.   1 80. — Aneurism  of  the  Aorta.     (Curschman.) 


rism,  are  to  be  heard  over  the  region  of  the  aortic  arch.  From  aortic 
stenosis  aneurism  is  distinguished  by  the  fact  that  it  does  not  diminish 
the  aortic  second  sound  or  produce  characteristic  changes  in  the  pulse, 
and  by  the  presence  of  some  one  of  the  symptoms  above  described,  such 
as  tracheal  tug,  pressure  symptoms,  abnormal  area  of  percussion  dul- 
ness, x-ray  shadow,  etc. 

(c)   Simple  dynamic  throbbing   of  a  normal   aortic   arch  similar 
to  that  which  occurs  in  the  abdominal  aorta  may  lift  the  chest  wall 


272 


PHYSICAL  DIAGNOSIS 


SO    as    to    simulate    aneurism.     The    other    positive    symptoms    and 
signs  of  aneurism  are,  however,  absent. 

(d)  Pulmonary  tuberculosis  or  cancer  of  the  oesophagus,  producing 
as  they  may  substernal  pain,  cough,  and  aphonia  by  pressure  upon 
mediastinal  structures,  have  been  mistaken  for  aneurism,  from  which, 
however,  they  may  be  distinguished  by  the  absence  of  the  positive 
signs  above  described,  by  the  more  rapid  emaciation  of  the  patient, 
and  by  the  positive  evidences  of  cancer  or  tuberculosis. 

(e)  Empyema  necessitatis  may  produce  a  pulsating  tumor  like  that 
of  aneurism  and  the  area  of  dulness  may  be  similar,  but  there  is  no 


Fig.  i8i. — Aneurism  of  the  Aorta  with  gumma. 


diastolic  shock,  no  tactile  thrill  or  murmur,  and  the  history  of  the  case 
and  the  x-raj  shadow  are  usually  very  different  from  that  of  aneurism. 

(/)  Mediastinal  tumors  are  sometimes  almost  indistinguishable 
from  aneurism  during  life.  They  may  produce  a  more  intense  and 
widespread  dulness  which  is  usually  in  the  median  line,  while  the  dul- 
ness of  aneurism  is  oftener  at  one  side.  The  pulsation  transmitted  to 
a  tumor  by  the  heart  has  not  the  expansile  character  of  aneurismal 
pulsation.  Tumors  are  not  associated  with  any  diastolic  shock, 
rarely  with  a  tracheal  tug. 

The  course  of  most  mediastinal  tumors  is  progressive  and  attended 


THORACIC  ANEURISM  273 

by  great  cachexia,  while  the  symptoms  of  aneurismi  are  often  more  or 
less  intermittent,  and  unless  pain  is  severe  there  is  no  such  emaciation 
or  anaemia  as  is  commonly  seen  with  mediastinal  tumors.  Pressure 
symptoms  may  be  the  same  in  both  diseases,  but  are  usually  more 
marked  with  mediastinal  growths.  A  metastatic  nodule  over  the 
clavicle  sometimes  betrays  the  presence  of  a  primary  focus  within 
the  chest. 

(g)  Retraction  of  the  right  lung  (fibroid  phthisis),  with  or  without 
displacement  of  the  heart  toward  the  diseased  side,  may  uncover 
the  heart  so  as  to  produce  some  of  the  signs  of  aneurism,  i.  e.,  pulsation 
and  dulness  in  the  upper  right  intercostal  spaces  near  the  sternum, 
with  a  loud  second  sound  and  sometimes  a  systolic  murmur  in  the 
dull   area. 

The  history  of  the  case  and  a  careful  examination  of  the  lungs  usu- 
ally suffice  to  set  us  right. 

{h)  Dilatation  of  the  heart  may  be  so  extreme  that  pulsation  and 
percussion  dulness  appear  in  the  characteristic  aneurismal  area  to  the 
right  of  the  sternum,  especially  if  there  is  solidification  of  the  left  lung. 
But  the  pulse  is  in  such  cases  much  weaker  and  more  irregular  than 
it  is  to  be  expected  in  uncomplicated  cases  of  aortic  aneurism,  and  the 
history  of  the  case  is  usually  decisive. 

By  the  same  marks  we  can  distinguish  the  pulsations  of  a  dilated 
heart,  which  sometimes  appear  in  the  left  hypochondrium. 


18 


CHAPTER  XV. 

DISEASES  OF  THE  LUNGS. 

BRONCHITIS,  PNEUMONIA,  TUBERCULOSIS. 
I.  Tracheitis. 

In  connection  with  bronchitis  or  as  a  forerunner  thereof,  inflam- 
mation of  the  trachea  is  not  uncommon.  It  gives  rise  to  no  charac- 
teristic physical  signs,  but  is  to  be  suspected  when  the  patient  com- 
plains of  cough  with  pain  over  the  upper  portion  of  the  sternum. 

Acute  Bronchitis. 

Inflammation  of  the  larger  bronchial  tubes  is  not  often  the  cause 
of  any  definite  physical  signs,  but  with  every  paroxysm  of  coughing  the 
patient  may  feel  pain  in  an  area  corresponding  exactly  to  the  anatom- 
ical position  of  the  primary  bronchi.  I  have  seen  patients  indicate 
most  accurately  the  situation  of  the  large  tubes  when  pointing  out  the 
position  of  pain  produced  by  coughing. 

In  the  vast  majority  of  cases  of  acute  bronchitis,  foci  of  broncho- 
pneumonia are  also  present,  but  the  physical  signs  are  usually  those  of 
an  inflammation  of  the  smaller  bronchi,  and  the  swelling  of  their 
walls,  with  or  without  exudation,  which  is  manifested  as  follows:^ 

(i)  Diminution  in  the  intensity  of  vesicular  breathing  over  the 
area  affected  (rarely  in  the  earliest  stages  the  breath  sounds  are 
exaggerated  and  harsh,  especially  in  the  upper  portions  of  the  chest) . 

(2)  Rales,  squeaking  or  piping  over  bronchi  which  are  narrowed 
without  any  considerable  amount  of  exudation,  as  is  the  case  in  the 
earliest  stages  of  many  cases,  and  bubbling,  crackling,  or  clicking  in 
later  stages,  when  watery  or  viscid  exudation  is  present  in  the  tubes. 
The  calibre  of  the  bronchi  affected  can  be  estimated  from  the  coarse- 
ness or  fineness  of  the  rales.  Low-pitched  groaning  sounds  point  to  a 
stenosis  of  a  relatively  large  bronchus,  while  squeaking  and  whistling 
sounds  are  usually  produced  in  the  smaller  tubes.     Large,  bubbling 

^  Bronchitis  may  exist  without  rales,  but  cannot  be  diagnosed  without  them.     Occa- 
sionally they  are  present  only  in  the  early  morning. 

274 


BRONCHITIS,  PNEUMONIA,  TUBERCULOSIS  275 

rales  are  much  less  often  heard  than  the  finer,  crackHng  variety.  The 
latter  are  produced  in  the  smallest  tubes,  the  former  in  the  larger 
variety. 

Simple  non-tuberculous  bronchitis  is  almost  invariably  bilateral 
or  symmetrical,  and  affects  most  often  the  lower  two-thirds  of  the 
lungs,  leaving  the  apices  relatively  free.  It  is  almost  never  confined 
to  an  apex.  When  rales  are  to  be  heard  on  one  side  of  the  chest  only, 
and  when  they  persist  in  the  same  spot  for  days  and  weeks,  tuberculosis 
is  always  to  be  suspected,  especially  if  the  rales  are  localized  at  the 
summit  of  one  or  both  lungs.  It  should  never  be  forgotten  that  the 
tubercle  bacillus  is  capable  of  exciting  a  bronchitis  indistinguishable 
from  other  varieties  of  bronchitis,  except  by  its  tendency  to  show  itself 
at  the  apex  of  the  lung  and  on  one  side  only;  most  cases  of  pulmonary 
tuberculosis  begin  in  this  way. 

The  only  other  variety  of  bronchitis  which  is  often  unilateral  is  that 
due  to  the  influenza  bacillus.  In  the  course  of  a  case  of  influenza,  a 
unilateral  localized  bronchitis  not  infrequently  occurs.  Over  a  patch 
of  lung,  perhaps  the  size  of  the  palm  of  the  hand,  fine,  moist  rales  may 
persist  for  weeks,  finally  clearing  up  only  after  the  patient  has  resumed 
his  ordinary  occupation.  Doubtless  such  locaHzed  patches  of  bronchi- 
tis are  often  accompanied  by  foci  of  lobular  pneumonia  too  small  to  be 
detected  by  our  present  methods  of  physical  examination. 

Percussion  dulness  is  absent  in  bronchitis  except  near  the  end  of 
fatal  cases,  when  the  lung  is  stuffed  with  mucus  and  pus,  or  when 
atelectasis  has  occurred  owing  to  extensive  plugging  of  the  larger 
bronchi.  These  events  are  rarely  seen,  and  in  general  the  negative 
results  of  percussion  are  of  great  value  in  excluding  soHdification  or 
fluid  exudation. 

Occasionally  percussion  resonance  may  be  increased  owing  to  a 
slight  temporary  overdistention  of  the  air  vesicles  from  coughing.^ 

Inspection  usually  shows  little  or  nothing  of  diagnostic  importance 
in  acute  bronchitis.  Long-standing  cases,  complicated  as  they  almost 
invariably  are  by  emphysema,  present  changes  in  the  shape  of  the 
thorax;  but  these  are  due  to  the  emphysema  rather  than  to  the  bron- 
chitis. In  children  acute  bronchitis  sometimes  involves  so  many  of 
the  smaller  bronchi  that  dyspnoea  and  use  of  accessory  muscles  of 
respiration  are  notable.  But  this  usually  means  atelectasis,  broncho- 
pneumonia, or  laryngeal  spasm,  in  addition  to  the  bronchitis. 

^  In  children  examined  during  a  crying-spell  a  cracked-pot  sound  can  usually  be 
elicited  by  percussion.  This  is  in  no  way  characteristic  of  bronchitis  and  can  often  be 
obtained  in  healthy  infants. 


276 


PHYSICAL  DIAGNOSIS 


From  violent  coughing  the  jugulars  may  be  distended,   but  no 
systolic  pulsation  occurs  in  them. 

Voice  sounds  and  tactile  fremitus  are  normal. 


Differential  Diagnosis. 

CEdema  of  the  lung  and  bronchial  asthma  are  the  only  pathological 
processes  (except  hemorrhage  into  the  lung  substance)  which  give 
rise  to  signs  like  those  of  bronchitis. 

(i)  In  oedema  of  the  lung,  or  in  pulmonary  apoplexy,  one  may  find, 
as  in  simple  bronchitis,  a  diminished  vesicular  breathing  with  crackling 
rales,  but  oedema  of  the  lung  is  almost  always 
best  marked  in  the  dependent  portions;  that 
is,  in  the  posterior  parts  of  the  lung  if  the 
patient  has  been  lying  upon  the  back,  or  in 
the  lower  lobes  if  he  has  been  sitting  up.  The 
rales  of  oedema  are  mostly  bubbles,  and  are 
more  uniform  in  size  when  compared  to  those 
of  bronchitis.  The  recognition  of  a  cause  for 
the  oedema,  for  example  a  non-compensated 
heart  lesion,  and  the  absence  of  fever  or 
leucocytosis  materially  aid  the  diagnosis. 

(2)  Bronchial  asthma  or  spasm  of  the  finer 
bronchi  produces  dry  squeaking  and  groaning 
sounds  similar  to  those  heard  in  the  earlier 
stages  of  many  cases  of  bronchitis.  But  in 
bronchial  asthma  fever  is  usually  absent,  the 
rales  are  chiefly  expiratory,  and  expiration  is 
prolonged  and  intensified.  Moreover,  the 
inhalation  of  a  few  drops  of  amyl  nitrite  will 
temporarily  dispel  rales  due  to  bronchial 
spasm,  while  on  the  rales  of  dry  bronchitis  it 
has  no  effect  (Abrams) . 

(3)  Broncho-pneumonia.  In  many  cases 
of  lobular  or  broncho-pneumonia  the  physical 
signs  are  exclusively  those  of  the  coexisting 

bronchitis.  In  such  cases  the  diagnosis  of  bronchitis  is  not  wrong, 
but  does  not  cover  the  whole  ground.  Indeed  I  am  doubtful  whether 
it  ever  does.  There  is  to  my  mind  no  proof  that  acute  bronchitis 
without  bronchopneumonia  ever  exists. 

(4)   Muscle  sounds.     Under  certain  circumstances  (cold,  nervous- 


FiG.  182.— The  Dots  are 
Placed  over  the  Area  where 
Atelectatic  Crepitation  is 
Oftenest  Heard. 


BRONCHITIS,  PNEUMONIA,  TUBERCULOSIS  277 

ness),  the  rumbling  noises  produced  by  muscular  contractions  in  the 
chest  wall  may  simulate  rales  so  closely  that  the  diagnosis  of  bronchitis 
may  be  strongly  suggested.  The  differentiation  between  rales  and 
muscle  sounds  has  already  been  discussed  (see  above,  p.  145). 

(5)  Atelectatic  crepitation.  Crackling  rales  heard  over  the  thin 
margins  of  the  lungs  at  the  base  of  the  axilla  or  along  the  edges  of  the 
manubrium  are  often  due  to  atelectasis  (see  above) .  From  bronchitis 
they  are  distinguished  by  their  situation  and  by  the  lack  of  symptoms. 
They  are  best  heard  at  the  point  shown  in  Fig.  182. 

Chronic  Bronchitis. 

So  far  as  the  bronchitis  itself  is  concerned,  there  may  be  no  dift'er- 
ence  in  the  physical  signs  between  the  acute  and  chronic  forms  of  the 
disease;  but  in  the  latter  one  almost  invariably  finds  associated 
with  the  bronchitis  itself  a  considerable  degree  of  emphysema,  of 
asthma,  and  of  bronchiectasis.  Indeed,  the  foreground  of  the  clinical 
picture  and  the  bulk  of  the  physical  signs  are  made  up  by  these  three 
diseases,  rather  than  by  the  bronchitis  itself.  Accordingly,  I  shall  not 
discuss  chronic  bronchitis  any  further  at  this  point,  but  will  return  to 
the  subject  in  the  chapters  on  Emphysema  and  on  Bronchiectasis. 
The  more  we  study  bronchitis  the  more  it  vanishes  from  sight  as  a 
clinical  entity.  ^^  Acute  bronchitis"  is  fast  turning  into  acute  broncho- 
pneumonia; "chronic  bronchitis"  is  being  recognized  as  bronchiectasis 
or  as  chronic  pulmonary  cedema  from  weak  heart  action. 

Croupous  Pneumonia. 

In  its  typical  form  croupous  or  fibrinous  pneumonia  produces 
solidification  of  one  or  more  lobes,  usually  the  lower,  the  process  being 
accurately  bounded  by  the  interlobular  fissures.  Although  the 
physical  signs  of  the  earlier  stages  differ  considerably  from  those  of 
the  later  ones,  there  seems  to  be  no  sufficient  ground  for  marking  off 
stages  of  engorgement  and  of  red  and  gray  hepatization,  for  clinically 
these  stages  cannot  be  distinguished. 

The  solidification  may  begin  in  the  deeper  parts  of  the  lung 
("central  pneumonia"),  so  that  no  physical  signs  are  obtainable  unless, 
later  in  the  course  of  the  disease,  the  process  extends  to  the  surface  of 
the  lung.  But  in  many  so-called  "central  pneumonias"  there  is  really 
no  localization  or  solidification  at  all.  The  process  is  an  acute  general 
pneumococcus  infection  which  may  later  settle  in  the  lung. 

Massive  pneumonia,  in  which  the  bronchi  as  well  as  the  air  cells  are 


278  PHYSICAL  DIAGNOSIS 

plugged  with  fibrin  and  leucocytes,  is  a  relatively  rare  form  of  the 
disease,  but  possesses  great  clinical  importance  on  account  of  the 
marked  resemblance  between  its  physical  signs  and  those  of  pleural 
effusion. 

The  frequency  of  endocarditis  and  pericarditis  in  connection  with 
lobar  pneumonias,  especially  with  those  of  the  left  side,  should  be 
borne  in  mind. 

Physical  Signs. 

(a)  Inspection. — The  aspect  of  the  patient  frequently  suggests  the 
diagnosis;  the  face  is  anxious,  often  flushed  or  slightly  cyanosed,  the 
flush  sometimes  affecting  most  strikingly  the  side  of  the  face  corres- 
ponding to  the  lung  affected.^  Herpetic  vesicles  ("cold  sores")  are 
often  to  be  seen  around  the  mouth  or  nose.  The  rapid,  difficult 
breathing  is  at  once  noticeable,  and  expiration  is  often  accompanied  by 
a  grunt.  The  use  of  the  accessory  muscles  of  respiration  and  the  dila- 
tation of  the  nostrils  attract  attention. 

The  combination  of  marked  dyspnoea  with  absence  of  dropsy  is 
met  with  more  frequently  in  pneumonia  than  in  any  other  disease. 
Both  sides  of  the  chest  usually  move  alike,  but  occasionally  the  affected 
side  shows  deficient  expansion  especially  in  the  later  stages  of  the 
disease,  and  the  other  side  of  the  chest  shows  increased  respiratory 
movements  (compensatory) .  Rarely  the  pulsations  of  the  heart  may 
be  transmitted  to  the  chest  wall  through  the  affected  lung. 

When  pneumonia  attacks  a  feeble  old  man,  or  follows  injuries 
(surgical  pneumonia),  its  onset  may  be  insidious,  and  none  of  the 
phenomena  just  described  may  be  seen. 

(6)  Palpation. — In  the  great  majority  of  cases  tactile  fremitus  is 
markedly  increased  over  the  affected  area,^  but  in  case  the  bronchi  are 
occluded  by  secretions  or  fibrinous  exudate,  fremitus  may  be  diminished 
or  altogether  absent.  A  few  hard  coughs  will  sometimes  clear  out  the 
tubes  and  thus  materially  assist  the  diagnosis.  Occasionally  an  increase 
in  superficial  temperature  of  the  affected  side  may  be  noticed  by  palpa- 
tion, and  rarely  one  feels  a  friction  rub  due  to  the  fibrinous  pleurisy 
which  almost  invariably  accompanies  the  disease. 

(c)  Percussion. — Over  the  area  affected  the  percussion  note  is  generally 
dull  and  may  be  almost  fiat,  except  in  the  earliest  and  latest  stages  of 
the  disease,  in  which  it  may  have  a  tympanitic  quality  with  or  without 

^  Perhaps  because  the  patient  is  apt  to  He  upon  the  affected  side. 

2  By  using  the  edge  instead  of  the  flat  of  the  hand  the  boundaries  of  solidified  lobes 
may  often  be  very  accurately  marked  out  by  means  of  the  tactile  fremitus. 


BRONCHITIS,  PNEUMONIA,  TUBERCULOSIS  279 

an  element  of  slight  dulness.  More  marked  tympany  is  usually  present 
over  the  unaffected  lobes  of  the  diseased  lung  (that  is,  over  the  upper 
lobes  in  the  great  majority  of  cases.) 

The  conditions  just  described  represent  the  great  majority  of  cases, 
but  the  following  exceptions  occur: 

(i)  In  the  pneumonias  of  children,  and  occasionally  in  adults, 
dulness  may  be  absent. 

(2)  When  the  lower  lobe  of  the  left  lung  is  affected,  a  distinctly 
tympanitic  quality  may  be  transmitted  to  the  consolidated  area 
from  a  distended  stomach  or  colon. 

(3)  In  central  pneumonia  there  may  be  no  change  in  the  percus- 
sion note,  or  it  may  be  unusually  full  and  deep  so  that  the  sound  side 
seems  dull  by  comparison. 

A  solidified  lobe  increases  so  much  in  size  that  the  area  of  dulness 
corresponding  to  it  often  seems  incredibly  large.  Thus,  although  the 
lower  lobe  reaches  in  health  not  more  than  half-way  up  the  scapula, 
when  solidified  it  produces  dulness  throughout  nearly  the  whole  back. 
The  right  base  is  the  most  frequent  seat  of  pneumonic  solidifications, 
but  the  dulness  corresponding  to  it  is  often  first  noticeable  in  the 
posterior  axillary  line.  A  dulness  appreciable  only  in  the  front  of  the 
chest  is  almost  sure  to  correspond  to  the  upper  lobe,  while  signs  in  the 
lower  part  of  the  right  axilla  correspond  to  the  middle  lobe.  Many 
cases  of  central  pneumonia  first  appear  at  the  surface  in  one  or  the 
other  axilla. 

As  regards  the  amount  of  solidification  needed  to  produce  per- 
cussion dulness,  Wintrich  says  that  the  minimum  is  a  patch  5  cm. 
in  diameter,  2  cm.  deep,  and  superficially  situated. 

Percussion  often  makes  us  aware  of  an  increased  resistance  or 
diminished  elasticity  of  the  affected  side,  although  the  resistance  is 
seldom  as  marked  as  in  large  pleural  effusions. 

(d)  Auscultation. — In  the  great  majority  of  cases  typical  tubular 
breathing  is  to  be  heard  over  the  affected  area.  Since  a  whisper  is 
practically  a  forced  expiration,  this  tubular  quality  is  very  well  brought 
out  if  the  patient  is  made  to  whisper  "one,  two,  three,"  or  any  other 
succession  of  syllables,  and  by  this  method  the  fatigue  and  pain  of 
deep  breathing  may  be  saved.  By  this  use  of  the  whispered  voice  one 
may  accurately  mark  out  the  boundaries  of  the  consolidated  area 
without  tiring  the  patient,  and  may  demonstrate  in  many  cases  that 
it  coincides  with  the  boundaries  of  one  lobe  of  the  lung. 

In  the  earliest  stages  of  the  disease  the  breathing  may  be  bron- 
cho-vesicular; more  often  it  is  feeble  or  suppressed  over  the  consolidated 


280 


PHYSICAL  DIAGNOSIS 


area,  and  "crepitant  rales,"  that  is,  very  fine  crackling  sounds,  may 
be  heard  at  the  end  of  inspiration,  but  these  are  much  more  common 
in  the  stage  of  resolution^  ("crepitans  redux"). 

If  some  of  the  smaller  bronchi  are  blocked,  as  is  not  infrequently 
the  case,  respiration  is  absent  or  very  feeble,  and  such  cases  are  often 
mistaken  for  pleuritic  effusion. 

In  cases  of  "central  pneumonia,"  that  is,  when  the  area  of  solidifi- 
cation is  in  the  interior  of  the  organ,  there  may  be  no  change  in  the 
breath  sounds,  or  a  bronchial  element  may  he  faintly  audible  on  auscul- 
tation with  the  unaided  ear,  and  only  by  this  method. 

^-  Tympany. 


Bronchial  breathing 
transmitted      by  - 
spinal  column  to 
sound  lung. 


—  Solidification. 


Fig.  183. — Diagram  of  Signs  in  Pneumonia. 


The  intensity  of  the  spoken  or  whispered  voice  is  greatly  increased 
over  the  area  of  consolidation,  and  sometimes  the  words  can  be  dis- 
tinguished. The  nasal  twang  known  as  ''  egophony"  is  occasionally 
to  be  heard.  It  the  majority  of  cases,  as  has  been  already  stated, 
the  right  lower  lobe  posteriorly  is  affected,  so  that  the  consolidated 
area  is  immediately  in  apposition  with  the  spinal  column.  Under 
these  circumstances,  it  is  not  at  all  uncommon  to  hear  bronchial 
breathing  transmitted  from  the  consolidated  lobe  to  a  narrow  zone 
close  along  the  spinal  co'umn  on  the  sound  side.  Such  a  zone  is 
often  mistaken  for  consolidation  (see  Fig.  183). 

The  signs  are  usually  less  marked  in  the  axilla  and  in  the  front  of 
the  lung,  but  in  a  minority  of  cases,  and  especially  when  the  upper 

'  Crepitant  rales  are  rarely  heard  in  the  pneumonias  of  infancy  and  old  age.  They 
are  not  peculiar  to  pneumonia,  but  occur  in  pulmonary  oedema  or  hemorrhagic  infarction 

— conditions  easily  distinguised  from  pneumonia. 


BRONCHITIS,  PNEUMONIA,  TUBERCULOSIS  281 

lobes  are  affected,  the  signs  are  wholly  in  the  front.  When  searching 
for  evidences  of  consolidation  in  persons  suspected  to  have  pneumonia, 
one  should  never  omit  to  examine  the  apices  and  very  summit  of  the 
armpit,  pressing  the  stethoscope  up  behind  the  anterior  fold  of  the 
axilla. 

In  examining  the  posterior  lobes,  when  the  patient  is  too  weak 
to  sit  up  and  is  loath  even  to  turn  upon  the  side,  the  Bowles  stetho- 
scope is  a  great  convenience,  owing  to  the  ease  with  which  its  flattened 
extremity  may  be  worked  in  between  the  patient  and  the  bed-clothes 
without  causing  any  discomfort. 

When  resolution  begins,  the  signs  may  almost  completely  disappear 
within  a  few  hours.  More  frequently  the  bronchial  breathing  is 
modified  to  broncho-vesicular,  dulness  and  bronchophony  become 
less  marked,  fine  crackling  rales  (crepitans  redux)  or  coarser  moist 
bubbles  appear,  and  the  lung  gradually  returns  to  its  normal  condition 
within  a  period  of  three  to  eight  days.  In  the  active  stages  of  the 
disease  the  entire  absence  of  rales  is  very  characteristic.  In  most 
cases  the  solidification  of  the  lung  persists  after  the  fall  of  the  tem- 
perature; indeed,  it  may  be  weeks  or  even  months  before  it  clears  up, 
and  yet  the  lung  may  be  perfectly  sound  in  the  end.  On  the  other 
hand,  abscess  or  gangrene  or  fibrosis  may  develop  in  the  solidified 
lobe.  Commonest  and  most  important,  however,  is  the  post-pneu- 
monic empyema  (basal  or  interlobar)  which  is  often  mistaken  for  delayed 
resolution.     The  latter  is  rare;  empyema,  common  (see  below,  p.  324). 

''Wandering  pneumonia''  is  a  term  applied  to  cases  in  which 
the  consolidation  disappears  in  one  lobe  only  to  reappear  in  another, 
or  spreads  gradually  from  lobe  to  lobe.  The  physical  signs  in  such 
cases  do  not  differ  essentially  from  those  already  described. 

Sum,mary. 

In  a  typical  case  one  finds   (oftenest  at  the  right  base  behind) 

1.  Dulness  on  percussion. 

2.  Increased  tactile  fremitus  and  voice  sounds. 

3.  Tubular  breathing  and  occasionally  crepitant  rales. 

These  signs  occurring  in  connection  with  fever,  cough,  rusty  sputa, 
pain  in  the  side,  dyspnoea,  herpes  and  leucocytosis  are  sufficient 
for  the   diagnosis. 

But  many  cases  are  not  typical  when  first  seen.  The  following 
are  the  commonest  anomalies : 

(a)  There  may  be  tympany  instead  of  dulness,  especially  in  children 
or  when  the  solidification  is  at  the  left  base. 


282  PHYSICAL  DIAGNOSIS 

(6)  The  breathing  may  be  feeble  but  vesicular  in  character,  or  it 
may  be  absent,  in  case  bronchi  are  plugged;  from  the  same  cause, 

(c)   Tactile  fremitus  may  be  diminished. 

A  hard  cough  may  clear  out  the  bronchi  and  produce  a  sudden 
metamorphosis  of  the  physical  signs  with  a  return  to  the  normal  type. 

In  these  atypical  cases,  we  have  to  fall  back  upon  the  symptoms, 
the  history,  the  blood,  and  sputa  for  help  in  the  diagnosis. 

Deep-seated  pneumonic  processes  may  appear  at  the  surface  in 
out-of-the-way  places,  e.g.,  at  the  summit  of  the  axilla,  and  the  area 
of  demonstrable  physical  signs  may  be  no  larger  than  a  silver  dollar. 
A  thorough  examination  of  every  inch  of  the  chest  is  therefore  essential 
in  doubtful  cases. 

In  the  later  stages  of  the  disease  crepitant  or  other  fine  rales  often 
appear,  and  the  signs  of  solidification  suddenly  or  gradually  disappear. 

Differential  Diagnosis. 

Pneumonic  solidification  is  to  be  distinguished  from 
(i)  Pleuritic  efi'usion,  serous  or  purulent. 

(2)  Tuberculosis  of  the  lung. 

(3)  Compression  of  the  lung. 

(i)  From  pleuritic  effusion,  pneumonia  is  to  be  distinguished  in  the 
great  majority  of  cases  by  differences  in  the  onset,  course,  and  general 
symptoms  of  the  disease.  In  pneumonia  the  patient  is  far  more 
suddenly  and  violently  attacked,  the  dyspnoea  is  much  greater,  cough 
and  pain  are  more  distressing  and  more  frequent,  the  temperature  is 
higher,  and  the  sputum  often  characteristic.  In  pleuritic  effusion  the 
dulness  is  usually  more  intense  than  in  pneumonia.  Tactile  fremitus 
and  voice  sounds  are  increased  in  pneumonia  (except  when  the  bronchi 
are  plugged) ;  decreased  or  absent  in  pleuritic  effusion.  Bronchial 
breathing  may  be  heard  in  both  diseases,  but  is  usually  feeble  and 
distant  when  occurring  in  pleurisy,  and  loud  in  pneumonia.  If  the 
affection  be  on  the  left  side,  the  diagnosis  is  much  aided  by  the  presence 
of  dislocation  of  the  heart,  which  is  produced  by  pleuritic  effusion  and 
never  by  pneumonia.  In  cases  of  pneumonia  with  occluded  bronchi, 
one  may  have  every  sign  of  pleuritic  effusion — flatness,  absent  breath- 
ing, voice  and  fremitus — and  in  such  cases  the  absence  of  any  disloca- 
tion of  the  heart,  provided  the  disease  is  upon  the  left  side,  is  very 
important.  If  a  similar  condition  of  things  occurs  upon  the  right  side, 
one  may  have  to  fall  back  upon  the  symptoms  and  upon  such  evidence 
as  the  blood  count,  herpes,  sputum,  etc. 


BRONCHITIS,  PNEUMONIA,  TUBERCULOSIS  283 

(2)  Tuberculosis  of  the  lung  causing,  as  it  may,  a  diffuse  solidifica- 
tion of  the  organ,  may  be  indistinguishable  from  pneumonia  if  we 
take  account  only  of  the  physical  signs,  but  the  two  diseases  can  usually 
be  distinguished  without  difficulty  by  the  difference  in  their  symptoms 
and  course,  and  by  the  presence  or  absence  of  tubercle  bacilli  in  the 
sputum. 

(3)  Compression  of  the  left  lung  by  a  pericardial  effusion  and  of 
either  lung  by  some  subdiaphragmatic  lesion  (perinephric  abscess, 
hepatic  abscess)  often  simulates  pneumonia,  indeed  the  physical  signs 
may  be  indistinguishable.  Diagnosis  depends  mostly  on  establishing 
the  presence  or  absence  of  a  cause  for  such  compression. 

Inhalation  Pneumonia.     Aspiration  Pneumonia. 

When  food  or  other  foreign  substances  are  drawn  into  the  air 
passages,  as  may  occur,  for  example,  during  recovery  from  ether 
narcosis,  a  form  of  broncho-pneumonia  may  be  set  up,  in  which  the 
solidified  patches  are  not  infrequently  large  enough  to  be  recognized 
by  the  ordinary  methods  of  physical  examination. 

The  lesions  are  usually  bilateral  and  accompanied  by  a  general 
bronchitis.  Slight  dulness  and  indistinct  bronchial  breathing  can 
usually  be  made  out  over  an  irregular  area  in  the  backs  of  both  lungs. 

The  signs  are  considerably  less  marked  than  in  croupous  pneu- 
monia, and  the  boundaries  of  the  irregular  patches  of  disease  do  not 
correspond  to  those  of  a  lobe  of  the  lung. 

If  not  rapidly  fatal,  the  disease  may  be  complicated  by  pulmonary 
gangrene  or  abscess  and  large  quantities  of  fetid  pus  may  be  spit  up. 

Broncho-Pneumonia. 

{Catarrhal  or  Lobular  Pneumonia.) 

Multiple  small  areas  of  solidification  scattered  through  both  lungs, 
interspersed  with  areas  of  collapse,  and  usually  associated  with  diffuse 
bronchitis,  occur  very  frequently  in  children,  producing  severe 
dyspnoea,  cyanosis,  cough,  and  somnolence,  and  running  a  very  fatal 
course. 

The  solidified  lobules  may  fuse  so  as  to  form  considerable  areas  of 
hepatized  lung,  or  there  may  be  no  lesion  larger  than  a  pea. 

This  is  the  usual  type  of  "lung  fever"  in  infants,  although  ordinary 
lobar  pneumonia  is  fully  as  common  in  older  children. 

The  widespread  atelectasis  of  the  lower  lobes  which  is  associated 


284  PHYSICAL  DIAGNOSIS 

with  the  disease  in  most  cases  owing  to  the  plugging  of  the  bronchi 
with  tenacious  secretions,  is  probably  as  serious  in  its  effects  as  the 
pneumonic  foci  themselves. 

The  anterior  and  upper  parts  of  the  lungs  often  become  distended 
with  air  (vicarious  emphysema)  and  render  the  physical  signs  very 
confusing  and  deceptive.  Much  milder  and  less  wide  spread  types  of 
broncho-pneumonia  often  run  their  course  under  the  name  of  "acute 
bronchitis"  and  are  not  discovered  unless  the  patient  happens  to  die 
of  some  other  cause.  The  physical  signs  are  merely  those  of 
bronchitis. 

Physical  Signs. 

In  the  majority  of  cases  there  are  no  characteristic  physical  signs, 
and  the  diagnosis  has  to  be  made  largely  from  the  symptoms  and 
course  of  the  disease.  The  consolidated  areas  are  usually  too  small  to 
give  rise  to  any  dulness  on  percussion,  or  to  any  change  in  the  breath 
sounds,  voice  sounds,  or  fremitus,  so  that  auscultation  shows,  as  a  rule, 
nothing  more  than  patches  of  fine  rales  occurring  at  the  end  of  expira- 
tion. Localized  tympanitic  resonance  is  sometimes  present  over  the 
diseased  area,  making  the  sounder  portions  of  the  lungs  seem  dull  by 
comparison.  Occasionally,  when  many  lobules  have  fused  into  a 
single  mass  of  larger  area,  the  ordinary  signs  of  consolidation  may  be 
obtained,  although  they  are  apt  to  disappear  within  twenty-four  or 
forty-eight  hours  and  appear  in  another  situation.  As  above  said,  the 
diagnosis  is  usually  to  be  made,  if  at  all,  from  the  combination  of  the 
physical  signs  of  a  localized  bronchitis  with  the  symptoms  of  pneumonia. 
" This  patient,"  we  say,  "has  only  the  signs  of  bronchitis,  but  he  is  too 
sick.  The  cyanosis,  dyspnoea,  and  fever  are  too  marked.  He  is 
sicker  than  simple  bronchitis  will  account  for,  but  I  am  in  doubt 
whether  there  is  any  such  thing  as  'simple  bronchitis.'  It  seems  to 
me  probable  that  what  has  usually  been  called  'simple  bronchitis' 
with  patches  of  rales  here  and  there  is,  in  fact,  a  relatively  mild  type 
of  broncho-pneumonia  with  some  associated  bronchitis." 

Differential  Diagnosis. 

(a)  Acute  pulmonary  tuberculosis  may  be  indistinguishable  from 
broncho-pneumonia  by  the  physical  signs  alone.  The  diagnosis 
must  be  made  from  the  history  and  course  of  the  disease  or  from  the 
presence  of  tubercle  bacilli  in  the  sputa. 

(6)  The  extensive  atelectasis  of  the  lower  lobes  which  may  accom- 


BRONCHITIS,  PNEUMONIA,  TUBERCULOSIS  285 

pany  broncho-pneumonia  gives  rise  to  dulness  and  absence  of  respira- 
tory and  vocal  sounds.  Thus,  the  signs  of  pleuritic  effusion  are 
simulated,  and  in  children  the  possibility  of  empyema  should  not  be 
forgotten.  As  a  rule,  broncho-pneumonia  gives  rise  to  much  greater 
dyspnoea,  and  is  associated  with  a  more  extensive  bronchitis,  than 
usually  coexist  with  pleural  effusion.  The  atelectatic  lobules  may  be 
expanded  by  coughing  or  by  the  cutaneous  stimulus  of  cold  water, 
and  thus  resonance  and  breath  sounds  may  suddenly  return.  With 
pleuritic     effusions,  of  course,  such  a  change  is  impossible. 


Tuberculosis  of  the  Lungs. 

(i)   Incipient  Tuberculosis. 

In  the  earlier  stages  of  the  disease  there  may  be  absolutely  no 
recognizable  physical  signs,  and  the  diagnosis  may  be  established 
only  by  the  positive  result  of  a  tuberculin  injection  or  by  the  combina- 
tion of  debility,  indigestion  or  loss  of  weight  with  slight  fever  not  other- 
wise to  be  accounted  for. 

In  some  cases  the  earliest  evidence  of  the  disease  is  hcemoptysis.'^ 
When  a  patient  consults  a  physician  on  account  of  haemoptysis,  it  is 
frequently  impossible  to  find  any  physical  signs  of  disease  in  the  lungs; 
not  until  weeks  or  months  later  do  the  characteristic  changes  recogniz- 
able by  physical  examination  make  their  appearance. 

The  very  early  hoarseness  of  the  voice  in  tuberculous  patients  is  of 
great  importance  and  often  attracts  our  attention  to  the  lungs  when 
the  patient  has  said  nothing  about  them.  Definite  physical  signs  in 
the  lungs  and  tubercle  bacilli  in  the  sputa  (artificially  obtained  through 
the  use  of  potassic  iodide,  see  below)  may  occasionally  be  demon- 
strated before  any  cough  has  appeared.  On  the  other  hand,  the 
patient  may  cough  for  weeks  before  anything  abnormal  can  be  dis- 
covered in  the  lungs.  Occasionally  tuberculosis  begins  with  an 
ordinarily  bilateral  bronchitis.  I  have  found  tubercle  bacilli  in  four 
such  cases.     More  often  the  earliest  physical  signs  are: 

(a)  Fine  crackling  rales  at  the  apex  of  one  lung,  heard  only  with 
or  after  cough  and  at  the  end  of  inspiration.  (More  rarely  squeaks 
may  be  heard.)      (See  Fig.  184). 

^  Never  percuss  a  patient  within  forty-eight  hours  after  a  hemorrhage,  and  never 
encourage  cough  or  forced  respiration  in  such  a  one.  There  is  danger  of  starting  a  fresh 
hemorrhage. 


286 


PHYSICAL  DIAGNOSIS 


(b)  A  slight  diminution  in  the  excursion  of  the  diaphragm  on  the 
affected  side,  as  shown  by  Litten's  diaphragm  shadow. 

(c)  SHght  diminution  in  the  intensity  of  the  respiratory  murmur, 
with  or  without  a  high  pitched  or  interrupted  inspiration  ("cog-wheel 
breathing"). 

(a)  In  examining  the  apices  of  the  lungs  for  evidence  of  early 
tuberculosis  one  should  secure  if  possible  perfect  quiet  in  the  room,  and 
have  the  clothes  entirely  removed  from  the  patient's  chest.  The 
ordinary  hard-rubber  chest-piece  is  better  than  the  chest-piece  of  the 


Rales.  ^^ 


Fig.  184. — Diagram  to  Show  Position  of  Earliest  Signs  in  Tuberculosis. 


Bowles  instrument,  and  both  the  chest-piece  and  the  skin  should  be 
wetted.  After  listening  during  quiet  breathing  over  the  apices  above 
and  below  the  clavicle  in  front,  and  above  the  spine  of  the  scapula 
behind,  the  patient  should  be  directed  to  breathe  out  and  then,  at  the 
end  of  expiration,  to  cough.  During  this  cough  and  the  deep  inspira- 
tion which  is  likely  to  precede  or  to  follow  it,  one  should  listen  as  care- 
fully as  possible  at  the  apex  of  the  lung,  above  and  below  the  clavicle, 
concentrating  attention  especially  upon  the  cough  itself  and  upon 
the  last  quarter  of  the  inspiration,  when  rales  are  most  apt  to  appear. 
Sometimes  only  one  or  two  crackles  may  be  heard  with  each  inspira- 
tion, and  not  infrequently  they  will  not  be  heard  at  all  unless  the- 
patient  is  made  to  cough,  but  even  a  single  rale,  if  persistent,^  is  impor- 
tant. In  children  who  cannot  cough  at  will,  one  can  accomplish 
nearly  the  same  result  by  making  them  count  as  long  as  possible  with 

^  Rales  heard  only  during  the  first  few  breaths  and  not  found  to  persist  on  subsequent 
examinations,  may  be  due  to  the  expansion  of  atelectatic  lobules. 


BRONCHITIS,  PNEUMONIA,  TUBERCULOSIS  287 

one  breath  and  then  hstening  to  the  immediately  succeeding  inspira- 
tion. When  Hstening  over  the  apex  of  the  lung,  one  should  never 
allow  the  patient  to  turn  his  head  sharply  in  the  other  direction, 
since  such  an  attitude  stretches  the  skin  and  muscles  on  the  side  on 
which  we  are  listening  so  as  to  produce  annoying  muscle  sounds  or 
skin  rubs. 

In  cases  in  which  one  suspects  that  incipient  tuberculosis  is  present 
and  yet  in  which  no  positive  evidence  can  be  found,  it  is  a  good  plan  to 
give  iodide  of  potassium,  (gr.  vii.  three  times  a  day)  for  a  few  days. 
The  effect  of  this  drug  is  often  to  make  rales  more  distinct,  and  some- 
times to  increase  expectoration  so  that  tubercle  bacilli  can  be  demon- 
strated when  before  none  were  to  be  obtained.^ 

(b)  The  diminution  in  the  excursion  of  the  diaphragm  upon  the 
affected  side  in  cases  of  incipient  phthisis  has  been  much  insisted  upon 
by  F.  H.  Williams  and  others  who  have  interested  themselves  in  the 
radioscopy  of  the  chest.  Litten's  diaphragm  shadow  gives  us  a 
method  of  observing  the  same  phenomenon  without  the  need  of  a 
fiuoroscope.  Even  very  slight  tuberculous  changes  in  the  lung  are 
sufficient  to  diminish  its  elasticity  and  so  to  restrict  its  excursion  and 
that  of  the  diaphragm.  Comparisons  must  always  be  made  with  the 
sound  side  in  such  cases,  as  individuals  differ  very  much  in  the  extent 
with  which  they  are  capable  of  depressing  the  diaphragm.  It  must 
be  remembered  that  pleuritic  adhesions,  due  to  a  previous  inflammation 
of  the  pleura,  may  diminish  or  altogether  abolish  the  excursion  of  the 
diaphragm  shadow,  independently  of  any  active  disease  in  the  lung 
itself. 

Those  who  are  expert  in  the  use  of  the  fiuoroscope  believe  that 
they  can  detect  the  presence  of  tuberculosis  in  the  lung  by  radioscopy 
at  a  period  at  which  no  other  method  of  physical  examination  shows 
anything  abnormal. 

Interrupted  or  cog-wheel  respiration,  in  which  the  inspiration  comes 
in  high-pitched  irregular  jerky  puffs  not  synchronous  with  the  cardiac 
impulse,  signifies  that  the  entrance  of  the  air  into  the  alveoli  is  im- 
peded, and  such  impediment  is  most  likely  to  be  due  to  tuberculosis 
when  present  over  a  considerable  period  in  a  localized  area  of  pulmon- 
ary tissue. 

^  Any  irritating  vapor — for  example,  creosote  vapor — v^^hich  produces  violent  cough 
and  expectoration,  may  be  used  to  expel  bronchial  secretions  in  doubtful  cases.  Tubercle 
bacilli  may  then  be  found  in  the  sputum  of  patients  who,  without  the  irritating  inhalation, 
have  no  cough  and  so  no  sputa,  but  this  is  in  my  opinion  a  dangerous  procedure,  as  it 
may  "Ught  up"  a  quiescent  process  in  the  lung. 


288  PHYSICAL  DIAGNOSIS 

(2)   Moderately  Advanced  Cases. 

So  far  I  have  been  speaking  of  the  detection  of  tuberculosis  at  a 
stage  prior  to  the  production  of  any  considerable  amount  of  solidifica- 
tion. The  signs  considered  have  been  those  of  bronchitis  localized  at 
the  apex  of  the  lung,  or  of  a  slightly  diminished  pulmonary  elasticity, 
whether  due  to  pleuritic  adhesions  or  to  other  causes.  We  have  next 
to  consider  the  signs  in  cases  in  which  solidification  is  present,  though 
relatively  slight  in  amount.  This  condition  is  comparatively  easy  to 
recognize  when  it  occurs  at  the  left  apex,  but  more  difficult  in  case 
only  the  right  apex  is  diseased.  Partial  solidification  of  a  small 
area  of  lung  tissue  at  the  left  apex  gives  rise  to 


Rales.  __^ 


-     Complete 
solidification. 


Partial 
"^  solidification. 


\ — Rales. 


Fig.   185. — Diagram  of  Signs  in  Phthisis. 

(a)   Slight  dulness  on  light  percussion,^  with  increased  resistance. 

(6)  Slight  increase  in  the  intensity  of  the  spoken  and  whispered 
voice,  and  of  the  tactile  fremitus  (in  many  cases) . 

(c)  Some  one  of  the  numerous  varieties  of  broncho-vesicular  breath- 
ing (true  bronchial  breathing  is  a  late  sign). 

{d)  Abnormally  loud  transmission  of  the  heart  sounds,  especially 
under  the  clavicle. 

In  case  there  is  also  a  certain  amount  of  secretion  in  the  bronchi 
of  the  affected  area  or  ulceration  around  them,  one  often  hears  rales  of  a 
peculiar  quality  to  which  Skoda  has  given  the  name  of  "  consonating 
rales."     Rales  produced  in  or  very  near  a  solidified  area  are  apt  to 

^  Other  causes  of  dulness,  such  as  asymmetry  of  the  chest,  pleural  thickening,  and 
tumors,   must  be   excluded.     Emphysema  of   the  lobules  surrounding  the  tuberculous 

patch  may  completely  mask  the  dulness. 


BRONCHITIS,  PNEUMONIA,  TUBERCULOSIS 


289 


have  a  very  sharp,  crackling  quaHty,  their  intensity  being  increased 
by  the  same  acoustical  conditions  with  increase  the  intensity  of  the 
voice  sounds  over  the  same  area.  When  such  rales  are  present  at  the 
apex  of  either  lung,  the  diagnosis  of  tuberculosis  is  almost  certain,  but 
if,  as  not  infrequently  occurs,  there  are  no  rales  to  be  heard  over  the 
suspected  area,  our  diagnosis  in  clear  only  in  case  the  signs  occur  at 
the  left  apex.  Precisely  the  same  signs,  if  present  at  the  right  apex, 
leave  us  in  doubt  regarding  the  diagnosis,  for  the  reason  that,  as  has 


Fig.  1 86. — This  Patient  has  SoUdification  at  both  Apices  and  Tubercle  Bacilli  in  the  Sputa. 

He  feels  perfectly  well. 


been  explained  above,  we  find  at  the  apex  of  the  right  lung  in  health 
signs  almost  exactly  identical  with  those  of  a  slight  degree  of  solidifica- 
tion. Hence,  if  these  signs,  and  only  these,  are  discovered  at  the  right 
apex,  we  cannot  feel  sure  about  the  diagnosis  until  it  is  confirmed  by 
the  appearance  of  rales,  the  presence  of  fever,  loss  of  weight,  a  positive 

19 


290  PHYSICAL  DIAGNOSIS 

tuberculin  reaction  (ocular,  cutaneous  or  subcutaneous),  or  by  the 
finding  of  tubercle  bacilli  in  the  sputum.^ 

A  sign  characteristic  of  early  tuberculous  changes  in  the  lung 
and  one  which  I  have  frequently  observed  in  the  lower  and  relatively 
sounder  lobes  of  tuberculous  lungs  is  a  raising  of  the  pitch  of  inspi- 
ration,^ without  any  other  change  in  the  quality  of  the  breathing  or  any 
other  physical  signs.  The  importance  of  this  sign  in  the  diagnosis 
of  early  tuberculosis  of  the  lungs  was  insisted  upon  by  the  elder  Flint 
in  his  work  on  "The  Respiratory  Organs"  (1866),  and  has  more  re- 
cently been  mentioned  by  Norman  Bridge.  I  have  referred  to  this 
sort  of  breathing  above  as  broncho  vesicular  breathing  of  the  first  {i.e., 
earliest)  type  (see  p.  152). 

It  must  never  be  forgotten  that  tuberculosis  may  take  root  in  the 
most  finely  formed  chests  and  in  persons  apparently  in  blooming  health. 
The  "phthisical  chest"  and  the  sallow,  emaciated  figure  of  the  classical 
descriptions  apply  only  to  very  advanced  cases.  Fig.  186  represents 
a  patient  with  moderately  advanced  signs  of  phthisis  and  abundant 
tubercle  bacilli  in  the  sputa.  He  feels  perfectly  well  and  is  at  work. 
On  the  other  hand,  a  patient  with  very  slight  signs  may  be  utterly 
prostrated  by  the  toxaemia  of  the  disease. 

(3)   Advanced  Phthisis. 

Characteristic  of  the  more  advanced  stages  of  tuberculosis  in  the 
lungs  is  the  existence  of  large  areas  of  solidified  and  retracted  lung, 
and,  to  a  lesser  extent,  the  signs  of  cavity  formation.  The  patients 
are  pale,  emaciated,  and  feverish.  The  signs  of  solidification  have 
already  been  enumerated  in  speaking  of  pneumonia.     They  are: 

1.  Marked  dulness,  or  even  flatness,^  with  increased  sense  of 
resistance. 

2.  Great  increase  of  voice  sounds  or  of  tactile  fremitus. 

3.  Tubular  breathing,  sometimes  loud,  sometimes  feeble. 

4.  As  a  rule,  coarse  rales,  due  to  breaking  down  of  the  caseous 
tissue,  are  also  to  be  heard  over  the  solidified  areas.  Sometimes  these 
rales  are  produced  within  the  pleuritic  adhesions,  which  are  almost 

1  The  natural  disparity  between  the  two  apices  is  less  marked  in  the  supraspinous  fossa 
behind  than  over  the  clavicle  in  front,  and  hence  pathological  dulness  at  the  apex  is 
more  often  demonstrable  behind  than  in  front. 

^  "Sharp  breathing"  (Turban). 

^  Unless  senile  emphysema  masks  it.  Fibroid  phthisis  {vide  infra)  may  show  no  dulness. 
Remember  that  gastric  tympany  may  be  transmitted  to  the  left  lung  and  mask  dulness 
there. 


BRONCHITIS,  PNEUMONIA,  TUBERCULOSIS 


291 


invariably  present  in  such  cases.  If  they  disappear  just  after  profuse 
expectoration,  one  may  infer  that  they  are  produced  within  the  lung. 

Increase  in  the  intensity  of  the  spoken  voice,  of  the  whispered 
voice,  or  of  the  tactile  fremitus  may  be  marked  and  yet  no  tubular 
breathing  be  audible.  Each  of  these  signs  may  exist  and  be  of  im- 
portance as  signs  of  solidification  without  the  others.  As  a  rule,  it  is 
true,  they  are  associated  and  form  a  very  characteristic  group,  but 
there  are  many  exceptions  to  this  rule. 

One  of  the  common  variations  from  the  typical  group  of  signs  just 
mentioned  occurs  in  the  fibroid  cases  with  pleural  thickening.  In 
these  the  breathing  may  be  everywhere  feeble,  though  the  presence  of  a 
few  rales  with  dulness  and  increased  voice  sounds  makes  the  diagnosis 
obvious.  In  any  almshouse  group  of  old  consumptives  one  finds 
(a)    cases  in  which   one  hears  much  that   strikes    the    novice — loud 


Bronchial  breath 
ing,  dulness. 


Increased  fremitus 


Increased  voice 
sounds. 


Rales 


'  Rales. 


Fig.  187. — To  Illustrate  Progress  of  Signs  in  Pulmonary  Tuberculosis. 


tubular  breathing,  abundant  rales,  etc.,  (b)  cases  where  there  is  very 
little  to  hear  with  the  stethoscope  and  that  little  not  in  itself  distinctive. 

The  tendency  of  the  spinal  column  to  transmit  to  the  sound  lung 
sounds  produced  in  an  area  of  solidification  immediately  adjacent  to 
it  on  the  other  side,  has  been  already  alluded  to  in  the  section  on 
pneumonia,  and  what  was  then  said  holds  good  of  tuberculous 
solidification.  Owing  to  this  it  is  easy  to  be  misled  into  diagnosing 
solidification  at  both  apices  when  only  one  is  affected. 

Since  solidification  is  usually  accompanied  by  retraction  in  the 
affected  lung  in  very  advanced  cases,  the  chest  falls  in  to  a  greater 


292  PHYSICAL  DIAGNOSIS 

or  less  extent  over  the  affected  area,  and  the  respiratory  excursion  is 
much  diminished,  as  shown  by  ordinary  inspection  and  by  the  diminu- 
tion or  disappearance  of  the  excursion  of  the  diaphragm  shadow. 
The  intensity  of  the  tubular  breathing  depends  on  the  proximity  of 
the  solidified  portions  to  the  chest  wall  and  to  the  large  bronchi,  as 
well  as  on  the  presence  or  absence  of  pleuritic  thickening. 

It  is  rare  to  find  a  whole  lung  solidified.  The  process,  beginning  at 
the  apex  or  just  below,  extends  down  as  far  as  the  fourth  rib  in  front, 
i.e.,  through  the  upper  lobe,  in  a  relatively  short  time,  but  below  that 
point  its  progress  is  comparatively  slow  and  the  lower  lobes  may  be 
but  little  affected  up  to  the  time  of  death.  On  the  relatively  sound 
side  the  exaggerated  (compensatory)  resonance  may  mask  the  dulness 
of  a  beginning  solidification  there,  which  sooner  or  later  is  almost  sure 
to  occur.  It  is  exceedingly  rare  for  the  disease  to  extend  far  in  one 
lung  without  involving  the  other. 

About  the  time  that  the  tuberculous  process  invades  the  previously 
sound  lung  it  is  apt  to  show  itself  at  the  apex  of  the  lower  lobe  of  the 
lung  first  affected.  Consonating  rales  appear  posteriorly  along  the 
line  which  the  vertebral  border  of  the  scajDula  makes  when  the  arm 
is  raised  over  the  shoulder.     These  points  are  illustrated  in  Fig.  187. 

Cavity  Formation. 

Cavities  of  greater  or  lesser  extent  are  formed  in  almost  every  case 
of  advanced  phthisis,  but  very  seldom  do  they  attain  such  size  as  to  be 
recognizable  during  life.  Indeed,  the  diagnosis  of  cavity  in  phthisis 
plays  a  much  larger  part  in  the  text-books  than  it  does  in  the  practice 
of  medicine,  since  to  be  recognizable  by  physical  examination  a  cavity 
must  not  only  be  of  considerable  size  but  its  walls  must  be  rigid  and 
not  subject  to  collapse,^  it  must  communicate  directly  with  the 
bronchus  and  be  situated  near  the  surface  of  the  lung,  and  it  must  not 
be  filled  up  with  secretions.  It  can  readily  be  appreciated  that  it  is 
but  seldom  that  all  these  conditions  are  present  at  once ;  even  then  the 
diagnosis  of  cavity  is  a  difficult  one,  and  I  have  often  known  skilled 
observers  to  be  mistaken  on  this  point. 

The  signs  upon  which  most  reliance  is  usually  placed  are : 

(a)   Amphoric  or  cavernous  breathing. 

{h)   "Cracked-pot  resonance"  on  percussion. 

(c)   Coarse,  gurgling  rales. 

(a)  Cavernous  or  Amphoric  Respiration. — When  present,  this  type 
of  breathing  is  almost  pathognomonic  of  a  cavity.  It  is  also  to  be 
^  Yet  not  so  rigid  as  to  be  uninfluenced  by  the  entrance  and  exit  of  air. 


BRONCHITIS,  PNEUMONIA,  TUBERCULOSIS  293 

heard  in  pneumothorax,  but  the  latter  disease  can  usually  be  dis- 
tinguished by  the  associated  physical  signs.  Cavernous  breathing 
differs  from  bronchial  or  tubular  breathing  in  that  its  pitch  is  lower  and 
its  quality  hollow.  The  pitch  of  expiration  is  even  lower  than  that  of 
inspiration.  Since  a  pulmonary  cavity  is  almost  always  surrounded 
by  a  layer  of  solidified  lung  tissue,  we  usually  hear  around  the  area 
occupied  by  the  cavity  a  ring  of  bronchial  breathing  with  which  we 
can  compare  the  quality  of  the  cavernous  sounds. 

{b)  Percussion  sometimes  enables  us  to  demonstrate  a  circum- 
scribed area  of  tympanitic  resonance  surrounded  by  marked  dulness. 
More  often  the  "cracked-pot"  resonance  can  be  elicited  by  percussing 
over  the  suspected  area  while  the  chest-piece  of  the  stethoscope  is 
held  close  to  the  patient's  open  mouth. 

Cracked-pot  resonance  is  often  absent  over  cavities;  rarely  occurs 
in  any  other  condition  {e.g.,  in  percussing  the  chest  of  a  healthy, 
crying  baby,  and  occasionally  over  solidified  lung). 

(c)  The  voice  sounds  sometimes  have  a  peculiar  hollow  quality 
(amphoric  voice  and  whisper) . 

{d)  Cough  or  the  movements  of  respiration  may  bring  out  over  the 
suspected  area  splashing  or  gurgling  sounds,  or  occasionally  a  metallic 
tinkle.  Flint  has  also  observed  a  circumscribed  bulging  of  an  inter- 
space during  cough.  Bruce  noted  a  high-pitched  sucking  sound 
during  the  inspiration  following  a  hard  cough  ("rubber-ball  sound"). 

Very  important  in  the  diagnosis  of  cavity  is  the  intermittence  of 
all  above-mentioned  signs,  which  are  present  only  when  the  cavity 
is  comparatively  empty,  and  disappear  when  it  becomes  wholly  or 
mostly  filled  with  secretions.  For  this  reason,  the  signs  are  very  apt 
to  be  absent  in  the  early  morning  before  the  patient  has  expelled  the 
accumulated  secretions  by  coughing. 

Wintrich  noticed  that  the  note  obtained  when  percussing  over  a 
pulmonary  cavity  may  change  its  pitch  if  the  patient  opens  his  mouth. 
Gerhardt  observed  that  the  note  obtained  over  a  pulmonary  cavity 
changes  if  the  patient  shifts  from  an  upright  to  a  recumbent  position. 
Neither  of  these  points,  however,  is  of  much  importance  in  diagnosis. 
The  same  is  true  of  metamorphosing  breathing  (see  above,  p.  154). 

Tuberculous  cavities  differ  from  those  produced  by  pulmonary 
abscess  or  gangrene  in  that  the  latter  are  usually  in  the  lower  two- 
thirds  of  the  lung.  Bronchiectasis,  if  considerable  in  extent,  cannot 
be  distinguished  by  physical  signs  alone  from  a  tuberculous  cavity, 
but  it  is  more  often  disseminated  (like  abscess  or  gangrene)  in  the 
lower  part  of  the  lungs  especially. 


294  PHYSICAL  DIAGNOSIS 

Fibroid  Phthisis. 

This  term  applies  to  slow  tuberculous  processes  with  relatively 
little  ulceration  and  much  fibrous  thickening. 

In  a  considerable  number  of  cases  the  physical  signs  do  not  differ 
materially  from  those  of  the  ordinary  ulcerating  forms  of  the  disease, 
but  occasionally  when  a  slow  chronic  process  at  the  apex  of  the  lung 
results  in  the  falling-away  of  the  parenchyma  of  the  lung  so  that  we 
have  left  a  cluster  of  bronchi  matted  together  by  fibrous  tissue,  the 
percussion  note  may  be  noticeably  tympanitic;  similar  tympany  may 
be  due  to  emphysema  of  the  lobules  surrounding  the  diseased  portion. 
In  such  cases  rales  are  usually  entirely  absent;  otherwise,  the  signs 
do  not  differ  from  those  of  ordinary  phthisis,  except  that  falling-in  of 
the  chest  walls  over  the  retracted  lung  may  be  more  marked.  Occa- 
sionally the  heart  may  be  drawn  toward  the  affected  lobes,  e.g.,  upward 
and  to  the  right  in  right-sided  phthisis  at  the  apex.  In  two  cases  of 
fibroid  disease  at  the  left  base,  Flint  found  the  heart  beating  near  the 
lower  angle  of  the  left  scapula. 

Phthisis  with  Predominant  Pleural   Thickening. 

Tuberculosis  in  the  lung  is  in  certain  cases  overshadowed  by  the 
manifestations  of  the  same  disease  in  the  pleura,  so  that  the  signs  are 
chiefly  those  of  thickened  pleura.  To  this  subject  I  shall  return  in  the 
section  of  Diseases  on  the  Pleura  (see  below,  p.  308). 

Emphysematous  Form  of  Phthisis. 

Tubercle  bacilli  are  not  very  infrequently  found  in  the  sputa  of 
cases  in  which  the  history  and  physical  signs  point  to  chronic  bron- 
chitis with  emphysema.  I  have  seen  two  cases  within  a  year.  Dulness 
is  wholly  masked  by  emphysema,  tubular  breathing  is  absent,  and 
piping  and  babbling  rales  are  scattered  throughout  both  lungs.  The 
emphysema  may  be  of  the  senile  or  small-lunged  type,  as  in  one  of  my 
recent  cases  (with  autopsy) ,  or  it  may  be  associated  with  huge  downy 
lungs  and  the  "barrel  chest."  Such  cases  cannot  be  identified  as 
phthisis  during  life  unless  we  make  it  an  invariable  rule  to  examine 
for  tubercle  bacilli  the  sputa  of  every  case  in  which  sputa  can  be 
obtained,  no  matter  what  are  the  physical  signs. 

Phthisis  with  Anomalous  Distribution  of  the  Lesions. 

Very  rarely  a  tuberculous  process  may  begin  at  the  base  of  the 
lung.  When  the  process  seems  to  begin  in  this  way,  a  healed  focus 
is  often  to  be  found  at  one  apex  surrounded  by  a  shell  of  healthy  lung. 


BRONCHITIS,  PNEUMONIA,  TUBERCULOSIS  295 

The  summit  of  the  axilla  should  always  be  carefully  examined,  as 
tuberculous  foci  may  be  so  situated  as  to  produce  signs  only  at  that 
point. 

Another  point  often  overlooked  in  physical  examination  is  the 
lingula  pidmonalis  or  tongue-like  projection  from  the  anterior  margin 
of  the  left  lung  overlapping  the  heart.  Tuberculosis  is  sometimes 
found  further  advanced  at  this  point  than  anywhere  else. 

As  a  rule  cases  in  which  signs  like  those  of  phthisis  are  found  at  the 
base  of  the  lung  turn  out  to  be  either  empyema,  or  abscess,  or  unre- 
solved pneumonia  (cirrhosis  of  the  lupg) . 

Acute  Pulmonary  Tuberculosis. 

No  one  of  the  three  forms  in  which  acute  phthisis  occurs,  viz., 

(a)   Acute  tuberculous  pneumonia, 

(6)    Acute  tuberculous  bronchitis  and  peribronchitis, 

(c)  Acute  miliary  tuberculosis,  involving  the  lungs,  can  be  rec- 
ognized by  physical  examination  of  the  chest.  The  first  form  is 
almost  invariably  mistaken  for  ordinary  croupous  pneumonia,  until 
the  examination  of  the  sputa  establishes  the  correct  diagnosis.  In 
the  other  two  forms  of  the  disease,  the  physical  signs  are  simply  those 
of  general  bronchitis. 


CHAPTER  XVI. 

EMPHYSEMA,  ASTHMA,  PULMONARY 
SYPHILIS,  ETC. 

I.  Emphysema. 

For  clinical  purposes,  the  great  majority  of  cases  of  emphysema 
may  be  divided  into  two  groups. 

(i)  Large-lunged  emphysema,  usually  associated  with  chronic 
bronchitis  and  asthma. 

(2)   Small-lunged,  or  senile,  emphysema. 

Although  the  second  of  these  forms  is  exceedingly  common,  it 
is  so  much  less  likely  than  the  first  form  to  give  rise  to  distressing 
symptoms  that  it  is  chiefly  the  large-lunged  emphysema  which  is  seen 
by  the  physician.  In  both  conditions  we  have  a  dilatation  and  finally 
a  breaking  down  of  the  alveolar  walls  until  the  air  spaces  are  become 
relatively  large  and  inelastic.  In  both  forms,  the  elasticity  of  the 
lung  is  diminished;  but  in  the  large-lunged  form  we  have  an  increase 
in  the  volume  of  the  whole  organ  in  addition  to  the  changes  just 
mentioned. 

Large-Lunged  Emphysema. 

The  diagnosis  can  usually  be  made  by  inspection  alone.  In  typical 
cases  the  antero-posterior  diameter  of  the  chest  is  greatly  increased, 
the  in-spaces  are  widened,  and  the  costal  angle  is  blunted,  while  the 
angle  of  Ludwig^  becomes  prominent.  The  shoulders  are  high  and 
stooping  and  the  neck  is  short  (see  Fig.  188).  The  patient  is  often 
considerably  cyanosed,  and  his  breathing  rapid  and  diificult.  In- 
spiration is  short  and  harsh;  expiration  prolonged  and  difficult.  The 
ribs  move  but  little,  and,  owing  to  the  ossification  of  their  cartilages, 
are  apt  to  rise  and  fall  as  if  made  in  one  piece  {en  cuirasse).  The 
working  of  the  auxiliary  muscles  of  respiration  is  not  infrequently 
seen.  The  diaphragm  shadow  (Litten's  sign)  begins  its  excursion  one 
or  two  ribs  farther  down  than  usual  and  moves  a  much  shorter  distance 
than  in  normal  cases. 

^  Formed  by  the  junction  of  the  manubrium  with  the  second  piece  of  the  sternum. 

296 


EMPHYSEMA,  ASTHMA,  PULMONARY  SYPHILIS,  ETC.  297 

Palpation  shows  a  diminution  in  the  tactile  fremitus,  throughout 
the  affected  portions;  that  is,  usually  throughout  the  whole  of  both 
lungs.     Sometimes  it  is  scarcely  to  be  perceived  at  all. 

Percussion  yields  very  interesting  information.  The  disease 
manifests  itself — 


Fig    i88. — Barrel  Chest  due  to.  Chronic  Bronchitis  and  Emphysema. 

(a)  By  hyper-resonance  on  percussion,  with  a  shade  of  tympanitic 
quality  in  the  note. 

(&)  By  the  extension  of  the  margins  of  the  lung  so  that  they  en- 
croach upon  portions  of  the  chest  not  ordinarily  resonant. 

The  degree  of  hyper-resonance  depends  not  only  upon  the  degree 
of  emphysema  but  upon  the  thickness  of  the  chest  walls.  The  note 
is  most  resonant  and  has  most  of  the  tympanitic  quality  when  the 


298  PHYSICAL  DIAGNOSIS 

disease  occurs  in  old  persons  with  relatively  thin  chest  walls.  The 
encroachment  of  the  over-voluminous  lungs  upon  the  liver  and  heart 
is  demonstrated  by  the  lowering  of  the  line  of  liver  flatness  from  its 
ordinary  position  at  the  sixth  rib  to  a  point  one  or  two  interspaces 
farther  down  or  even  to  the  costal  margin,  while  the  area  of  cardiac 
dulness  may  be  altogether  obliterated,  the  lungs  completely  closing 
over,  the  surface  of  the  heart.  At  the  apices  of  the  lungs  resonance 
ma}^  be  obtained  one  or  two  centimetres  higher  than  normally  and  the 
quality  may  be  markedly  tympanitic.  In  the  axillae  and  in  the  back 
the  pulmonary  resonance  extends  down  one  inch 
or  more  below  its  normal  position. 

Auscultation  shows  in  uncomplicated  cases  no 
very  marked  modification  of  the  inspiratory  mur- 
mur, which,  however,  may  be  shortened  and  enfee- 
bled. The  most  striking  change  is  a  great  pro- 
longation and  enfeeblement  of  expiration,  with  a 
Fig.      189.— Dia-     lowering  of  its  pitch  (see  Fig.  189). 

gram  us  ra  e  fhis  type  of  breathing  is  like  bronchial  breath- 

Emphysematous  ^ 

Breathing  with  Musi-  ^^S  in  one  respect;  namely,  that  m  both  of  them 
cal  Expiratory  Rales,  expiration  is  made  prolonged,  but  emphysematous 
breathing  is  feeble  and  low-pitched,  while  bronchial 
breathing  is  intense  and  high-pitched.  At  the  bases  of  the  lungs  the 
respiration  is  especially  feeble  and  may  be  altogether  replaced  by 
crackling  rales. 

In  '  'small-lunged  emphysema' '  we  have  precisely  the  same  physical 
signs,  except  that  the  boundaries  of  the  lung  are  not  extended,  expira- 
tion is  less  prolonged  and  less  difficult,  and  inspiration  is  normal. 
It  does  not  tend  to  be  complicated  by  bronchitis  and  asthma ;  indeed 
the  small-lunged  emphysema  rarely  gives  rise  to  any  symptoms, 
and  is  discovered  as  a  matter  of  routine  physical  examination. 

Summary. 

1.  Hyper-resonance  on  percussion. 

2.  Feeble  breathing  with  prolonged  expiration. 

3.  Diminished  fremitus  and  voice  sounds. 

4.  Encroachment  of  the  resonant  lungs  on  the  heart  and  liver 
dulness  (in  the  large-lunged  form). 

Differential  Diagnosis. 

(a)  Emphysema  may  be  confounded  with  pneumothorax,  since  in 
both  conditions  hyper-resonance   and  feeble   breathing   are   present. 


EMPHYSEMA,  ASTHMA,  PULMONARY  SYPHILIS,  ETC.  299 

But  emphysema  is  usually  bilateral,  encroaches  upon  but  does  not 
displace  neighboring  organs,  and  is  not  often  associated  with  hydro- 
thorax.  Emphysema,  if  extensive,  is  usually  associated  with  chronic 
bronchitis  and  so  with  squeaking  or  bubbling  rales,  while  in  pneumo- 
thorax breathing  is  absent  or  distant  amphoric  without  rales. 

(6)  The  signs  of  aneurism  of  the  aorta  pressing  on  the  trachea 
or  on  a  primary  bronchus  are  sometimes  overlooked  because  the  fore- 
ground of  the  clinical  picture  is  occupied  by  the  signs  of  a  coexisting 
bronchitis  with  emphysema.  The  cough  and  wheezing  which  the 
presence  of  the  aneurism  produces  may  then  be  accounted  for  as  part 
of  the  long-standing  bronchitis,  and  the  dulness  and  thrill  over  the 
upper  sternum  to  which  the  aneurism  naturally  gives  rise  may  be 
masked  by  extension  of  lung  borders.  But  the  evidence  of  pressure 
on  mediastinal  nerves  and  vessels  (aphonia,  unequal  pulses  or  pupils, 
etc.) ,  and  the  presence  of  a  diastolic  shock  and  tracheal  tug  are  usually 
demonstrable;  the  danger  is  that  we  shall  forget  to  look  for  them. 

(c)  Uncompensated  m^itral  stenosis  may  produce  dyspnoea  and 
cyanosis  and  weak  rapid  heart  action  somewhat  similar  to  that  seen  in 
emphysema,  and  may  not  be  associated  with  any  cardiac  murmur,  but 
the  dyspnoea  is  not  of  the  expiratory  type,  and  the  irregularity  of  the 
heart,  with  evidence  of  dropsy  and  general  venous  stasis,  should  make 
it  evident  that  something  more  than  simple  emphysema  is  present. 

{d)  The  occurrence  of  an  emphysematous  form  of  phthisis  I  have 
already  mentioned  in  discussing  the  latter  disease  (see  p.  294). 

Emphysem.a  with  Bronchiectasis,  Bronchitis  or  Asthma. 

In  the  great  majority  of  cases,  emphysema  of  the  lungs  is  associated 
with  chronic  bronchitis,  bronchiectasis,  and  asthmatic  paroxysms. 
Such  association  is  especially  frequent  in  elderly  men  who  have  had  a 
winter  cough  for  many  years  and  in  whom  arterio-sclerosis  is  more  or 
less  well  marked.  In  such  cases  the  prolonged  and  feeble  expiration 
is  usually  accompanied  by  squeaking  and  groaning  sounds,  or  by 
moist  rales  of  various  sizes  and  in  various  parts  of  the  chest.  When 
the  asthmatic  element  predominates,  dry  rales  are  more  noticeable, 
and  occur  chiefly  or  wholly  during  expiration,  while  inspiration  is 
reduced  to  a  short,  quick  gasp. 

Interstitial  EmphyscTna. 

In  rare  cases  violent  paroxysms  of  coughing  may  rupture  the  walls 
of  the  alveoli  so  as  to  allow  the  passage  of  air  into  the  interstitial 


300  PHYSICAL  DIAGNOSIS 

tissue  of  the  lung,  from  whence  it  may  work  through  and  manifest 
itself  under  the  skin,  giving  rise  to  a  peculiar  crackling  sensation  on 
palpation,  and  to  a  similar  sound  on  auscultation.  More  frequently  the 
trouble  arises  in  connection  with  a  tracheotomy  wound,  the  air  pene- 
trating under  the  skin  and  producing  a  downy,  crepitating  swelling. 

"Complementary  Em,physem,a." 

When  extra  work  is  thrown  upon  one  lung  by  loss  of  the  function 
of  the  other,  as  in  pleuritic  effusion — a  considerable  stretching  of  the 
overworked  sound  lung  may  take  place.  The  elasticity  of  the  lung  is 
not  diminished  as  in  emphysema,  but  is  greatly  increased.  Hence  the 
term  complementary  emphysema  should  be  dropped  and  the  term 
complementary  (or  compensatory)  hyper-resonance  substituted. 

Like  emphysema,  this  condition  leads  to  hyper-resonance  on  per- 
cussion and  to  encroachment  of  the  pulmonary  margins  upon  the 
neighboring  organs  (as  shown  by  a  reduction  in  the  area  of  dulness 
corresponding  to  them) ,  but  the  respiratory  murmur  is  exaggerated  and 
has  none  of  the  characteristics  of  emphysematous  breathing. 

A  word  may  here  be  added  regarding  the  condition  described  by 
West  under  the  name  of 

Acute  Pulmonary  Tympanites. 

In  fevers  and  other  acute  debilitating  conditions  West  has  observed 
that  the  lungs  may  become  hyper-resonant  and  somewhat  tympanitic 
on  percussion,  owing,  he  believes,  to  a  loss  of  pulmonary  elasticity. 
The  tympanitic  note,  often  observable  around  the  solidified  tissue  in 
pneumonia,  is  to  be  accounted  for,  he  believes,  in  the  same  way.  Like 
the  shortening  of  the  first  heart  sound,  acute  pulmonary  tympanites 
points  to  the  weakening  of  muscle  fibre  which  toxaemia  is  so  apt  to 
produce.  Apparently  the  muscle  fibres  of  the  lung  suffer  like  those 
of  the  heart. 

BRONCHIAL  ASTHMA. 

(Primary  Spasm  of  the  Bronchi.) 

During  a  paroxysm  of  bronchial  asthma  our  attention  is  attracted 
even  at  a  distance  by  the  loud,  wheezing,  prolonged  expiration 
preceded  by  an  abortive  gasping  inspiration.  The  breathing  is 
labored,  much  quickened  in  rate,  and  cyanosis  is  very  marked.  The 
chest  is  distended  and  hyper-resonant,  the  position  of  the  diaphragm 


EMPHYSEMA,  ASTHMA,  PULMONARY  SYPHILIS,  ETC.  301 

low  and  its  excursion  much  limited,  and  the  cardiac  and  hepatic  dul- 
ness  obHterated  by  the  resonance  of  the  distended  lungs.  On  ausculta- 
tion, practically  no  respiratory  murmur  is  to  be  heard  despite  the 
violent  plunging  of  the  chest  walls.  We  hear  squeaks,  groans, 
muscular  rumbles,  and  a  variety  of  strange  sounds,  but  amid  them  all 
practically  nothing  is  to  be  heard  of  the  breath  sounds.  "The  asth- 
matic storm  flits  about  the  chest,  now  here  now  there,"  the  rales 
appearing  and  disappearing. 

At  the  extreme  base  of  the  lungs  there  may  be  dulness  due  to 
atelectasis  of  the  thin  pulmonary  margins. 

Differential  Diagnosis. 

(a)  Mechanical  irritation  of  the  bronchi,  as  by  the  pressure  of  an 
aneurism  or  enlarged  gland,  may  set  up  a  spasm  of  the  neighboring 
bronchioles  much  resembling  that  of  primary  bronchial  asthma,  but 
thorough  examination  should  reveal  other  evidence  of  mediastinal 
pressure,  and  the  history  of  the  case  is  very  different  from  that  of 
asthma. 

(6)  Spasm  of  the  glottis  produces  a  noisy  dyspnoea,  but  the  diffi- 
culty is  with  inspiration,  instead  of  with  expiration,  and  the  crowing 
or  barking  sound  is  not  like  the  long  wheeze  of  asthma.  No  rales  are 
to  be  heard,  and  the  signs  in  the  lungs  are  those  of  collapse  instead  of 
the  distention  characteristic  of  asthma. 

(c)  The  paroxysmal  attacks  of  dyspnoea,  which  often  occur  in 
chronic  nephritis,  myocarditis,  and  other  diseases  of  the  heart  and 
kidney,  may  be  entirely  indistinguishable  from  primary  bronchial 
asthma  but  for  the  evidence  of  the  underlying  cardiac  or  renal  disease. 

{d)  Acute  dyspnoea  in  young  infants  is  sometimes  due  to  enlarged 
thymus  {thymic  asthma).  The  diagnosis  rests  on  the  elimination  of 
all  other  causes  for  sudden  dyspnoea  and  the  presence  (sometimes)  of 
increased  substernal  dulness  when  the  child  is  put  face  downwards. 

SYPHILIS  OF  THE  LUNG. 

The  diagnosis  cannot  be  made  with  certainty  from  the  physical 
signs,  and  rests  entirely  (in  the  rare  cases  in  which  it  is  made  at  all) 
on  the  history,  the  evidence  of  syphilis  elsewhere  in  the  body,  and  the 
result  of  treatment.     Most  cases  are  mistaken  for  phthisis. 

Any  case  supposed  to  be  phthisis,  but  in  which  the  examination  of 
the  sputa  for  tubercle  bacilli  is  repeatedly  negative,  should  be  given 
a  course  of  anti-syphilitic  treatment. 


302  PHYSICAL  DIAGNOSIS 

The  physical  signs,  as  in  phthisis,  are  those  of  localized  bronchitis 
or  bf  solidification,  but  the  lesions  are  not  at  the  apex  but  usually 
about  the  root  of  the  lung  or  lower  down.  Cavities  are  not  formed. 
Stenosis  of  a  bronchus  may  occur  with  resulting  atelectasis  of  the 
corresponding  lobules. 

Bronchiectasis  (Bronchial  Dilatation). 

(a)  The  commonest  type  is  that  associated  with  chronic  bronchitis 
and  recurrent  attacks  of  winter  cough.  Innumerable  small  bron- 
chioles become  dilated  and  the  resulting  cavity  is  repeatedly  infected — 
usually  with  influenza  bacilli  (Wm.  H.  Smith).  The  signs  may  be 
simply  those  of  a  chronic  bronchitis  with  or  without  emphysema  and 
asthmatic  seizures,  but  the  appearance  of  profuse  purulent  (not  muco- 
purulent) sputa  in  rounded  masses  is  distinctive.  Foci  of  broncho- 
pneumonia appear  from  time  to  time  with  acute  febrile  attacks.  In 
summer  the  cavities  are  often  dry  and  uninfected. 

(6)  When  the  disease  is  further  advanced  and  the  cavities  are 
larger,  a  sudden  change  in  the  patient's  position  (or  especially  hanging 
head  downward  over  the  side  of  the  bed)  may  cause  him  to  raise  large 
amounts  of  sputa  (half  a  pint  or  more)  within  a  few  minutes.  This 
sputum  is  not  usually  foul  and  rarely  contains  blood  or  elastic  fibres. 
Even  at  this  stage  there  may  be  no  physical  signs  of  localized  cavities — 
but  only  those  of  the  associated  bronchitis,  usually  more  marked  at 
one  base  than  at  the  other  and  associated  with  signs  of  partial 
solidification. 

(c)  In  a  small  number  of  cases  signs  of  cavity  (see  above,  p.  292) 
may  be  made  out. 

From  pulmonary  abscess  the  disease  may  usually  be  distinguished 
by  the  history,  the  sputa,  and  the  fact  that  local  signs  of  cavity  sur- 
rounded by  solidification  and  bronchitis  can  usually  be  demonstrated 
in  abscess. 

The  disease  may  cause  marked  retraction  of  the  chest  on  the 
affected  side,  and  neighboring  organs  may  be  drawn  out  of  place. 

Cirrhosis  of  the  Lung. 
{Chronic  Interstitial  Pneumonia.) 

As  an  end  stage  of  unresolved  croupous  pneumonia,  or  as  a  result 
of  chronic  irritation  from  mineral  or  vegetable  dust,  a  shrinkage  of  a 
part  or  the  whole  of  the  lung  may  occur,  which  progresses  until  the 
pulmonary  tissue  is  transformed  into  a  fibrous  mass  enclosing  bronchi. 


EMPHYSEMA,  ASTHMA,  PULMONARY  SYPHILIS,  ETC.  303 

The  side  of  the  chest  corresponding  to  the  affected  lung  becomes 
shrunken  and  concave;  fremitus  is  increased,  percussion  resonance 
diminished  or  lost,  respiration  tubular  with  coarse  rales. 

From  tuberculosis  the  condition  is  to  be  distinguished  solely  by 
the  history,  the  absence  of  bacilli  in  the  sputa,  and  the  comparative 
mildness  of  the  constitutional  symptoms. 

The  right  ventricle  of  the  heart  may  become  hypertrophied  and 
later  dilated  with  resulting  tricuspid  insufficiency. 

EXAMINATION     OF    SPUTA. 

I.  Origin. — Probably  the  majority  of  all  sputa,  excepting  tobacco 
juice,  come  from  the  nasopharynx,  and  are  hawked,  not  coughed  up. 
It  is  rarely  of  value  to  examine  such  sputa,  although  influenza  bacilli, 
diphtheria  bacilli,   pneumococci,   and   other  bacteria  may  be  found. 

What  we  want  in  most  cases  is  sputa  coughed  up  from  the  primary 
bronchi  or  lower  down,  and  the  patient  should  be  accordingly  in- 
structed. Early  morning  cough  is  most  likely  to  bring  up  sputa  from 
the  bronchi. 

Young  children  do  not  raise  sputum,  but  when  it  is  important  to 
obtain  it  we  may  insert  the  forefinger  (covered  with  a  bit  of  cotton) 
into  the  pharynx,  so  as  to  excite  a  spasm  of  coughing.  The  sputum  is 
deposited  on  the  cotton  before  the  child  has  time  to  swallow  it,  and 
may  then  be  withdrawn  and  examined. 

II.  Quantity. — If  the  amount  expectorated  is  large  {i.e.,  one-half 
a  pint  or  more  in  twenty-four  hours) ,  we  may  be  dealing  with : 

1.  Pulmonary    oedema    (watery,    sometimes    p'nk    and    frothy). 

2.  Advanced  phthisis  (mu co-purulent) . 

3.  Empyema  ruptured  into  a  bronchus  (pure  pus  not  separated 
into  pellets). 

4.  Abscess  of  the  lung  (foul  smelling). 

5.  Bronchiectasis  (large  amount  of  pure  pus  in  pellets  often  ex- 
pectorated within  a  few  minutes  on  change  of  position) . 

III.  Odor. — Unless  retained  in  a  lung  cavity  (abscess,  gangrene) 
sputum  is  rarely  ill-smelling.  In  gangrene  of  the  lung  the  breath  as 
well  as  the  sputum  is  horribly  offensive,  and  the  odor  soon  fills  the 
room  and  the  house. 

IV.  Gross  Appearances. — (a)  Bloody  sputum  (haemoptysis)  means 
pure  or  nearly  pure  blood  in  considerable  quantity,  a  teaspoonful  or 
more,  not  mere  streaks  of  blood  in  muco-purulent  sputum,  which 
usually  comes  from  an  irritated  throat. 


304  PHYSICAL  DIAGNOSIS 

Hgemoptysis  thus  defined  is  seen  chiefly  in  the  following  conditions, 
arranged  in  the  order  of  frequency: 

1.  Phthisis. 

2.  Pulmonary  congestion  with  infarction  (mitral  disease). 

3.  Pneumonia. 

4.  After  epistaxis. 

5.  Abscess  or  gangrene  of  the  lung. 

6.  Without  known  cause  ("vicarious  menstruation,"  etc.); 
Rare  causes  are  new  growths  of  the  lung,  parasites  (Distomum 

Westermanni) ,  aortic  aneurism  rupturing  into  an  air  tube,  ulcer  of  the 
trachea  or  bronchi. 

The  cause  of  haemoptysis  can  usually  be  made  out  by  a  thorough 
examination  of  the  chest  and  a  study  of  the  other  symptoms  in  the 
case.  In  phthisis  there  are  often  no  physical  signs  in  the  lungs  at  the 
period  when  the  bleeding  occurs  or  for  some  weeks  after  it.  Blood 
coughed  up  can  usually  be  distinguished  from  blood  vomited  {hcemat- 
emesis)  by  careful  questioning  and  by  examining  the  blood.  Blood 
coughed  up  often  contains  bubbles  of  air  and  is  alkaline  in  reaction, 
while  blood  from  the  stomach  is  usually  mixed  with  food,  not  frothy, 
and  perhaps  acid  in  reaction. 

(b)  Pneumonic  Sputum. — The  color  is  most  characteristic;  it  is 
either 

(i)   Tawny-yellow  or  fawn-colored   ("rusty"),  or 

(2)    Orange-juice    colored    {not  orange,    but   pale   straw-colored). 

These  colors,  associated  with  great  tenacity,  so  that  the  sputum 

clings  to  the  lips  and  does  not  fall  from  an  inverted  sputum-cup,  are 

almost    pathognomonic    of    pneumonia — though    pneumonia    often 

occurs  without  any  such  sputa. 

(c)  Serous  sputuin,  profuse  and  watery,  is  characteristic  of  pul- 
monary oedema. 

(d)  Black  or  gray  sputum  is  due  to  carbon,  dust,  or  tobacco  smoke 
inhaled. 

(e)  Pure  pus — not  muco-purulent —  is  oftenest  seen  in  influenza 
and  bronchiectasis,  occasionally  in  empyema  breaking  through  the 
lung. 

(/)  Muco-purulent  sputum  occurs  in  many  diseases  and  is  character- 
istic of  none. 

IV.  Microscopic  Examination. — Ninety-nine-one-hundredths  of  all 
examinations  are  for  the  tubercle  bacillus.  Of  the  many  useful 
methods  of  staining  for  this  organism  the  following  seems  to  me 
the  best; 


EMPHYSEMA,  ASTHMA,  PULMONARY  SYPHILIS,  ETC.  305 

1.  Pick  out  with  forceps  the  most  purulent  portion  of  the  sputa 
and  smear  it  thinly  over  a  cover  glass.  All  particles  thick  enough  to  be 
opaque  should  be  removed  from  the  cover  glass  before  staining. 

2.  Dry  the  preparation  held  in  the  fingers  over  a  Bunsen  or  alcohol 
flame.  Then  fix  it  in  Cornet's  forceps  and  pass  it  three  times  through 
the  flame,  sputum  side  down. 

3.  Flood  it  with  carbolic  fuchsin,^  and  steam  it — do  not  boil  it — 
over  the  flame  for  about  thirty  seconds.  Be  sure  to  use  enough  stain 
so  that  it  does  not  dry  on  the  cover  glass. 

4.  Wash  in  water  and  decolorize  for  twenty  seconds  in  twenty- 
per-cent.  H2SO4. 

5.  Wash  in  water  and  then  in  ninety-five-per-cent.  alcohol  for  thirty 
seconds  or  until  the  color  ceases  to  come  out. 

6.  Wash  in  water  and  cover  with  Loffler's  methylene  blue'  for 
about  thirty  seconds. 

7.  Wash  in  water,  dry  on  blotting  paper,  and  mount  in  Canada 
balsam. 

The  whole  process  need  not  take  more  than  five  minutes,  and  it  is 
absolutely  essential  that  every  physician  should  be  familiar  with  it. 

The  bacilli  are  stained  red,  everything  else  blue.  They  should 
be  looked  for  only  with  an  immersion  lens  (one-twelfth-inch),  a  wide- 
open  diaphragm,  and  a  good  white  light.  In  the  vast  majority  of 
cases  the  bacilli  are  found,  if  at  all,  within  a  few  minutes  and  in  almost 
every  field.  Occasionally  one  has  to  search  longer,  but  it  is  better 
to  search  one  well-stained  preparation  thoroughly  than  to  spend  the 
time  in  preparing  and  examining  several. 

The  presence  of  red-stained  bacilli  in  specimens  of  sputa  so  prepared 
is  practically  pathognomonic  of  tuberculosis.  Other  acid-resisting 
bacilli  occur  in  the  urine,  but  almost  never  in  the  lung. 

.  The  absence  of  tubercle  bacilli  after  at  least  six  examinations  of 
satisfactory  specimens^  obtained  several  days  apart  makes  it  very 
unlikely  that  phthisis  is  present.  One  or  two  negative  examinations 
are  of  no  signifiance. 

Pneumococcic  and  Influenza  Bacilli. — For  both  these  organisms 
Gram's  stain  is  on  the  whole  the  best.     This  is  performed  as  follows: 

^  Carbolic-acid  crystals,  5  gm.;  fuchsin  (saturated  alcoholic  solution),  10  gm.;  water, 
100  gm. 

"  Saturated  alcoholic  solution  of  methylene  blue,  30  c.c;  aqueous  solution  of  KOH 
(i  in  10,000),  100  c.c. 

'  A  satisfactory  specimen  is  one  prepared  without  any  slips  in  technique  from  purulent 
sputa  obtained  by  coughing  and  not  by  hawking. 
20 


306 


PHYSICAL  DIAGNOSIS 


1.  Prepare  a  smear  as  above  directed. 

2.  Cover     it     with     anil!ne-oil-gentian-violet     solution^     (freshly 
made  each  week)  and  heat  to  steaming  point. 

3.  Wash  in  water  and  cover  with  IKI  solution^  for  thirty  seconds. 

4.  Wash  in  ninety-five-per-cent.  alcohol  until  the  blue  color  ceases 
to  come  out. 

5.  Counterstain  with  Bismarck  brown  for  thirty  seconds. 

6.  Wash  in  water  and  mount  in  Canada  balsam. 

The  pneumococcus  with  this  stain  comes  out  blue-black  and  its 
morphology  is  well  shown   (see  Fig.    190).     The  presence  of  a  few 


Fig.  190. — Pneumococci  in  Sputum.     (W.  H.  Smith.)     (Gram's  stain.) 


pneumococci  free  in  the  sputum  is  not  of  importance.  When 
the  organisms  are  very  abundant,  and  especially  when  many  of  them 
are  contained  within  leucocytes,  a  pneumococcus  infection  is  strongly 
suggested,  though  it  may  be  a  pneumococcus  bronchitis  without 
pneumonia.  In  the  earliest  stages  of  an  infection  fewer  organisms 
are  found  within  leucocytes  than  is  the  case  later.  Obviously  one  can 
learn  only  by  practice  what  is  meant  by  "few"  or  "many"  organisms. 

^  Saturated  alcoholic  solution  of  gentian  violet,  13  c.c;  aniline  water,  84  c.c;  aniline 
water  is  the  clear  filtrate  from  the  mixture  of  aniline,  5  parts,  with  water,  25  parts. 
2  Iodine,  i  gm.;  potassium  iodide,  2  gm.;  water,  300  c.c. 


EMPHYSEMA,  ASTHMA,  PULMONARY  SYPHILIS,  ETC.  307 

The  influenza  bacillus  is  the  smallest  organism  to  be  found  in  the 
sputum.  In  specimens  stained  by  Gram's  method  (as  above  given) 
the  influenza  bacilli  come  out  as  minute,  faintly  brown-stained  points, 
contrasting  with  the  intense  blue-black  of  pneumococci  and  other 
organisms.  Only  when  present  in  large  numbers  both  inside  and 
outside  the  leucocytes  of  the  sputa  are  they  diagnostic  of  active  in- 
fluenzal infection,  since  the  organism  is  a  common  inhabitant  of  the 
upper  air  passages. 

Although  other  organisms — actinomyces,  micrococcus  catarrhalis, 
streptococcus,  bacillus  mucosus  capsulatus — are  sometimes  found  in 
sputa,  their  importance  does  not  justify  an  account  of  them  here. 

Indications  for  Sputum  Examination. — Any  cough  with  sputa 
lasting  more  than  a  week  calls  for  an  examination  of  sputa.  In 
doubtful  cases  of  influenza  or  pneumonia,  and  in  any  case  in  which 
tuberculosis  is  suspected  an  examination  is  imperative. 

When  the  symptoms  or  physical  signs  suggest  tuberculosis  but 
no  sputa  can  be  obtained,  it  is  well  to  stimulate  the  bronchial  secre- 
tions with  lo  gr.  of  potassium  iodide  after  meals  for  a  week.  A 
way  of  getting  sputa  from  young  children  has  already  been  described 
(page  303). 


CHAPTER  XVII. 

DISEASES  AFFECTING  THE  PLEURAL  CAVITY. 

I.  Hydrothorax. 

In  cases  of  nephritis  or  of  cardiac  weakness  due  to  valvular  heart 
disease  a  considerable  accumulation  of  serum  may  take  place  in  both 
pleural  cavities.  The  physical  signs  are  identical  with  those  of  pleu- 
ritic effusion  (see  below,  page  315)  except  that  the  latter  is  almost 
always  unilateral,  while  hydrothorax  is  usually  bilateral.  Exceptions 
to  this  rule  occur,  however,  especially  on  the  right  side  or  in  cases  in 
which  one  pleural  cavity  has  been  obliterated  by  fibrous  adhesions, 
the  results  of  an  earlier  pleurisy.  The  fluid  obtained  by  tapping  in 
cases  of  hydrothorax  is  usually  considerably  lower  in  specific  gravity 
and  poorer  in  albumin  than  that  exuded  in   pleuritic  inflammation. 

The  fluid  shifts  more  readily  with  change  of  position  than  is  the 
case  with  many  pleuritic  effusions,  owing  to  the  absence  of  adhesions 
in  hydrothorax. 

Friction  sounds,  of  course,  do  not  occur,  as  the  pleural  surfaces 
are  not  inflamed.  A  few  grains  of  potassium  iodide  by  mouth  soon 
produce  a  reaction  for  iodine  in  the  fluid  of  hydrothorax  and  not  in 
pleuritic  effusion. 

II.   Pneumothorax. 

Pneumothorax,  or  the  presence  of  air  in  the  pleural  cavity,  may 
result  from  stabs  or  wounds  of  the  chest  wall,  but  is  usually  a  com- 
plication of  pulmonary  tuberculosis  which  weakens  the  lung  until 
by  a  slight  cough  or  even  by  the  movements  of  ordinary  respiration 
the  pulmonary  pleura  is  ruptured  and  air  from  within  the  lung  leaks 
into  the  pleural  cavity. 

If  the  opening  is  of  considerable  size,  and  the  air  is  not  hindered 
or  encapsulated  by  adhesions,  great  and  sudden  dyspnoea  with  pain 
and  profound  "shock"  may  result.  More  commonly  the  onset  of 
symptoms  is  insidious,  the  air  enters  the  pleural  cavity  gradually, 
the  other  lung  has  time  to  hypertrophy,  and  the  heart  and  other  organs 
become  gradually  accustomed  to  their  new  situations. 

308 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY  309 

Physical  Signs. 

1.  Inspection. — The  affected  side  may  lag  behind  considerably  in 
the  movements  of  respiration.  In  very  marked  cases  it  is  almost 
motionless  and  the  interspaces  are  more  or  less  obliterated.  The 
diaphragm  is  much  depressed  and  Litten's  sign  absent.  In  right- 
sided  pneumothorax,  which  is  relatively  rare,  the  liver  is  depressed 
and  the  edge  can  be  felt  below  the  ribs. 

The  heart  is  displaced  as  by  pleuritic  effusion,  but  usually  to  a  less 
extent.  With  left-sided  pneumothorax  the  cardiac  impulse  may  be 
lowered  as  well  as  displaced,  owing  to  the  descent  of  the  diaphragm. 

2.  Palpation. — Fremitus  is  usually  diminished  or  absent  over  the 
lower  portions  of  the  chest  corresponding  to  the  effused  air.  At  the 
summit  of  the  chest  over  the  retracted  lung,  fremitus  is  also  diminished 
or  absent  as  a  rule  (W.  B.  James).  In  rare  cases  when  the  lung  is 
adherent  to  the  chest  wall  and  cannot  retract,  fremitus  is  preserved. 

The  positions  of  the  heart  and  liver  are  among  the  most  impor- 
tant points  determined  by  palpation.  Not  infrequently  no  cardiac 
impulse  is  to  be  obtained.  Sometimes  it  may  be  felt  to  the  right 
of  the  sternum  (see  Fig.  191)  or  in  the  left  axilla,  but  not  infrequently 
it  is  so  fixed  by  pleuropericardial  adhesions  that  it  is  drawn  upward 
toward  the  retracted  lung  or  remains  near  its  normal  situation. 
The  liver  is  greatly  depressed  in  cases  of  right-sided  pneumothorax, 
and  may  be  felt  as  low  as  the  navel. 

3.  Percussion. — Loud  tympanitic  resonance  is  the  rule  through- 
out the  affected  side.  Even  a  small  amount  of  air  is  sufficient  to  ren- 
der the  whole  side  tympanitic  and  often  to  obscure  the  dulness  which 
the  frequently  associated  pleural  effusion  would  naturally  produce. 
Indeed,  it  is  the  rule  that  small  effusions  are  wholly  masked  by 
the  adjacent  tympany. 

In  no  other  disease  do  we  get  such  clear,  intense  tympanitic 
resonance  over  the  chest. 

The  only  exception  to  this  rule  occurs  in  cases  in  which  the  air 
within  the  chest  is  under  great  tension,  making  the  chest  walls  so 
taut  that,  like  an  over- stretched  drum,  they  cannot  vibrate  properly. 
Under  these  conditions  the  percussion  note  becomes  muffled,  at  times 
almost  dull. 

Areas  of  dulness  corresponding  to  the  displaced  organs  (heart 
or  liver)  may  sometimes  be  percussed  out. 

4.  Auscultation. — Respiration  and  voice  sounds  are  usually  in- 
audible in  the  lower  portions  of  the  chest.     At  the  top  of  the  chest. 


310  PHYSICAL  DIAGNOSIS 

and  rarely  in  the  lower  parts,  a  faint  amphoric  or  metallic  breathing 
may  be  heard,  but  as  a  rule  the  amphoric  quality  is  brought  out  much 
better  by  cough  which  is  followed  by  a  ringing  after-echo.  In  W.  B. 
James's^  ninety  cases  the  breathing  was  amphoric  in  thirty-one, 
diminished  or  absent  in  fifty- three,  bronchial  in  six.  Or  the  air  in 
the  pleura  may  be  set  to  vibrating  and  made  to  give  forth  its  char- 
acteristic, hollow,  ringing  sound  if  a  piece  of  metal  (e.g.,  a  coin)  be 
placed  on  the  back  of  the  chest  and  struck  with  another  coin,  while 
we  listen  with  the  stethoscope  over  the  front  of  the  chest  opposite  the 
point  where  the  coin  is.  In  the  combined  satistics  of  Emerson^  and 
James ^  the  signs  were  present  in  forty-five  out  of  sixty  cases,  or  seventy- 
five  per  cent. 

The  clear  ringing  sound  heard  in  this  way  is  quite  different  from 
the  dull  chink  obtainable  over  sound  lung  tissue. 

The  "falling-drop  sound"  or  "metallic  tinkle,"  (see  above,  p.  165), 
was  heard  in  thirty  out  of  thirty-five  of  James's  cases. 

On  the  sound  side  the  breath  sounds  are  exaggerated.  At  the 
top  of  the  affected  side  over  the  collapsed  lung  the  breathing  is  bron- 
chial and  rales  are  occasionally  heard. 

In  the  great  majority  of  cases  pneumothorax  is  complicated  by 
an  effusion  of  fluid  in  the  affected  pleural  cavity  and  we  have  then 
the  signs  of 

III.  Pneumohydrothorax  or  Pneumopyothorax. 

When  both  fluid  and  air  are  contained  in  the  pleural  cavity,  the 
patient  may  himself  be  able  to  hear  the  splashing  sounds  which 
the  movements  of  his  own  body  produce.  These  are  more  readily 
appreciated  if  the  observer  puts  his  ear  against  the  patient's  chest 
and  then  shakes  him  briskly.  Splashing  sounds  heard  within  the 
chest  are  absolutely  pathognomonic  and  point  only  to  the  combina- 
tion of  fluid  and  air  within  the  pleural  cavity.  One  must  distinguish 
them,  however,  from  similar  sounds  produced  in  the  stomach.  By 
observing  the  position  of  maximum  intensity  of  the  sounds,  this 
distinction  may  be  easily  made.  Unfortunately  the  critical  condition 
of  the  patient  may  make  it  impossible  to  try  succussion,  as  in  the  acute 
cases  with  great  shock  it  is  dangerous  to  move  patients  at  all. 

The  movements  of  breathing  or  coughing  may  bring  out  a  "metal- 
lic tinkle"   (see  above,  p.   165).     At  the  base  of  the  chest,  over  an 

^  Osier's  Modern  Medicine,  Vol.  Ill,  p.  881. 

*  Emerson:  Pneumothorax,  Johns  Hopkins  Hospital  Reports,  1903,  Vol.  XI. 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY  311 

area  corresponding  to  the  position  of  the  fluid,  an  area  of  dulness  may 
be  easily  marked  out  by  percussion,  and  this  area  shifts  very  markedly 
with  change  of  position.  The  shifting  dulness  of  pneumohydrothorax 
is  strongly  in  contrast  with  the  difficulty  of  obtaining  any  such  shift 
in  ordinary  pleuritic  effusion  (see  Fig.  192). 

(The  distinction  between  ''open  pneumothorax,"  in  which  the  rent 
in  the  lung  through  which  the  air  escaped  in  the  pleura  remains  open, 
and  "closed  pneumothorax"  in  which  the  rent  has  become  obliterated — 
is  one  which  cannot  be  established  by  physical  signs  alone.  It  is 
often  said  that  amphoric  breathing,  and  especially  an  amphoric  ring 


Fig.  igi. — Left  Pneumohydrothorax  Seen  from  Behind.  Note  the  horizontal  line  at 
the  surface  of  the  fluid  and  the  retracted  lung  just  above  the  inner  half  of  this  Une.  The 
heart  is  displaced  to  the  right.     Compare  Fig.  197.     (From  v.  Ziemssen's  Altas.) 

to  the  voice  and  cough  sounds,  denote  an  open  pneumothorax,  but 
post-mortem  evidence  does  not  bear  this  out.  Practically  an  open 
pneumothorax  is  one  in  which  the  amount  of  effused  air  increases, 
and  closed  pneumothorax  is  one  in  which  the  physical  signs  remain 
stationary.) 

Differential  Diagnosis. 

The    distinction    between    pneumothorax    and    emphysema    has 
already  been  discussed. 


312 


PHYSICAL  DIAGNOSIS 


(a)  When  the  air  in  the  pleural  sac  is  under  such  tension  that  the 
percussion  note  is  dull,  the  physical  signs  may  simulate  pleuritic 
effusion,  but  real  flatness,  such  as  characterizes  effusion,  has  not,  so 
far  as  I  know,  been  recorded  in  pneumothorax,  and  the  sense  of 
resistance  on  percussing  is  much  greater  over  fluid  than  over  air.  In 
case  of  doubt  pucture  is  decisive. 

(&)  Acute  pneumothorax,  coming  on  as  it  does  with  symptoms  of 
collapse  and  great  shock,  may  be  mistaken  for  angina  pectoris,  cardiac 
failure,  embolism  of  the  pulmonary  artery,  or  acute  pulmonary  tym- 
panites (see  above,  p.  294). 


f  Tympany, 

I  breathing 

Air=  J  ^^^  voice 

^  absent  or 

faint 

amphoric 


Dulness, 
shifting 
Fluid  =  {        with 

I  change  of 
[   position. 


Liver.   —  —  —  — 


Fig.  192. — Left  Pneumoserothorax  with  Displaced  Heart. 

From  all  these  it  can  be  distinguished  by  the  presence  of  amphoric 
or  metallic  sounds,  which  are  never  to  be  obtained  in  the  other  affec- 
tions named. 

(c)  Hernia  of  the  intestine  through  the  diaphragm  (see  Fig.  193) 
or  great  weakening  of  the  diaphragmatic  muscular  fibres,  may  allow 
the  intestines  to  encroach  upon  the  thoracic  cavity  and  simulate 
pneumothorax  very  closely.  The  history  and  course  of  the  case,  the 
abdominal  pain,  vomiting,  and  indicanuria,  generally  suffice  to  dis- 
tinguish the  condition.  The  peristalsis  of  the  intestine  may  go  on  even 
in  the  thorax,  and  gurgling  metallic  sounds  corresponding  to  it  and 
unlike  anything  produced  in  the  thorax  itself  may  be  audible. 

The  distinction  between  open  and  closed  pneumothorax,  to  which 
I  have  already  alluded,  is  far  less  important  than  the  presence  or 
absence  of 

(a)  Pulmonary  tuberculosis. 


DISEASES  AFFECTING  TFIE  PLEURAL  CAVITY  313 

(b)  Encapsulating  adhesions  in  which  the  air  is  confined  to  a 
circumscribed  area. 

(a)  The  examination  of  the  sputa  and  of  the  compressed  lung  may 
yield  evidence  regarding  tuberculosis.  On  the  sound  side  the  com- 
pensatory hypertrophy  covers  up  foci  of  dulness  or  rales  so  that  it  is 
difficult  to  make  out  much. 


Fig.  193. — Diaphragmatic  Hernia.     The  outhne  of  the  displaced  diaphragm  visible  below 
the  left  clavicle.     Heart  displaced  to  right  of  sternum.     (From  v.  Ziemssen's  Atlas.) 


(6)  Encapsulated  pneumothorax  gives  us  practically  all  the  signs 
of  a  phthisical  cavity,  from  which  it  is  distinguished  by  the  fact  that 
with  a  cavity  the  nutrition  of  the  patient  is  almost  always  much  worse. 

Encapsulated  pneumothorax  needs  no  treatment.  Hence  the 
importance  of  distinguishing  it  from  the  non-encapsulated  form  of 
the  disease,  in  which  treatment  is  essential. 

PLEURISY. 

Clinically,  we  deal  with  three  types: 

(a)  Dry  or  plastic  pleurisy. 

(b)  Pleuritic  effusion,  serous  or  purulent. 

(c)  Pleural  thickening. 


314 


PHYSICAL  DIAGNOSIS 


(a)   Dry  or  Plastic  Pleurisy. 

Doubtless  many  cases  run  their  course  without  being  recognized. 
The  frequency  with  which  pleuritic  adhesions  are  found  post  mortem 
would  seem  to  indicate  this. 

It  is  usually  the  characteristic  stitch  in  the  side  which  suggests 
physical  examination.     The  pain  and  the  physical  signs  resulting  from 
the  fibrinous  exudation  are  usually  situated  at  the  bottom  of  the  axilla 
where  the  diaphragmatic  and  costal  layers  of  the  pleura  are  in  close 
apposition.      Doubtless   the  pleuritic  inflam- 
mation is  not  by  any  means  limited  to  this 
spot,   but   it   is  here  that  the  two  layers  of 
the  pleura  make  the  largest  excursion  while 
in  apposition  with  each  other.     In  the  vast 
majority  of  cases,  then,  the  physical  signs  are 
situated  at  the  spot  indicated  in  Fig.  194. 

Occasionally  pleuritic  friction  is  to  be 
heard  in  the  precordial  region,  and  after  the 
absorption  of  a  pleuritic  efifusion  evidences  of 
fibrinous  exudation  in  the  upper  parts  of  the 
chest  are  sometimes  demonstrable.  Most 
rarely  of  all,  evidence  of  plastic  pleurisy  may 
be  found  at  the  apex  of  the  lung  in  connec- 
tion with  early  phthisis.  In  diaphragmatic 
pleurisy,  when  the  fibrinous  exudation  is 
especially  marked  upon  the  diaphragmatic 
pleura,  friction  sounds  may  be  heard  over 
the  region  of  the  attachment  of  the  dia- 
phragm in  front  and  behind  as  well  as  in  the 
axillae.  Hiccup  often  occurs  and  gives  exquisite 
pain. 

Our  diagnosis  is  based  upon  a  single  physi- 
cal sign,  pleuritic  friction.  The  nature  of  this 
sound  has  already  been  described  (see  above, 
p.  162),  and  I  will  here  only  recapitulate 
During  the  first  few  deep  breaths  one  hears, 
while  listening  over  the  painful  area,  a  grating  or  rubbing  sound 
usually  somewhat  jerky  and  interrupted,  most  marked  at  the  latter 
part  of  inspiration,  but  often  audible  throughout  the  whole  respiratory 
act.  After  a  few  breaths  it  often  disappears,  but  will  usually  reappear 
if  the  patient  lies  for  a  short  time  upon  the  affected  side,  and  then  sits 


Fig.  194. — Showing  the 
Point  at  which  Pleural 
Friction  is  most  Often 
Heard. 

what  was  there  said. 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY  315 

Up  and  breathes  deeply.  In  marked  cases  the  rubbing  of  the  inflamed 
pleural  surfaces  may  be  felt  as  well  as  heard,  and  it  is  not  very  rare  for 
the  patient  to  be  able  to  feel  and  hear  it  himself.  Pleuritic  friction 
may  be  present  and  loud  without  giving  rise  to  any  pain.  On  the 
other  hand,  the  pain  may  be  intense,  and  yet  the  friction-rub  barely 
audible.  When  heard  at  the  summit  of  the  chest,  as  in  cases  of 
incipient  phthisis,  pleural  friction  produces  only  a  faint  grazing  sound, 
much  more  delicate  and  elusive  than  the  sounds  produced  at  the  base 
of  the  chest. 

Occasionally  the  distinctive  rubbing  or  grating  sounds  are  more 
or  less  commingled  with  or  replaced  by  crackling  sounds  indistin- 
guishable from  the  drier  varieties  of  rales.  It  is  now,  I  think,  gener- 
ally believed  that  such  sounds  may  originate  in  the  pleura  as  well  as 
within  the  lung.  The  greatest  care  should  be  taken  to  prevent  any 
shifting  or  slipping  of  the  stethoscope  upon  the  surface  of  the  chest, 
as  by  such  means  sounds  exactly  like  those  of  pleural  friction  may  be 
transmitted  to  the  ear.  In  case  of  doubt  one  should  always  wet  the 
skin  and  the  stethoscope  so  that  the  latter  cannot  slip. 

Muscle  sounds  are  sometimes  taken  for  pleural  friction,  but  they 
are  bilateral,  usually  low-pitched,  sound  less  superficial  than  pleu- 
ral friction,  and  are  not  increased  by  pressure.  When  listening  for 
friction  at  the  base  of  the  left  axilla,  I  have  once  or  twice  been  puzzled 
by  some  low-pitched  rumbling  sounds  occurring  at  the  end  of  inspira- 
tion, and  due  (as  afterward  appeared)  to  gas  in  the  stomach  which 
shifted  its  position  with  each  descent  of  the  diaphragm. 

The  transmitted  shoulder-joint  crepitus,  audible  in  the  back  when 
the  patient's  arms  are  crossed  in  front  (F.  T.  Lord),  has  been  described 
on  p.  163. 

In  children  friction  sounds  and  pleuritic  pain  are  much  less  com- 
mon than  in  adults,  and  the  signs  first  recognizable  are  those  of  effusion. 
In  adults  the  presence  of  a  very  thick  layer  of  fat  may  make  it  difficult 
or  impossible  to  feel  or  hear  pleural  friction. 

The  breath  sounds  over  the  affected  area  are  usually  absent  or 
greatly  diminished,  owing  to  the  restraint  in  the  respiratory  move- 
ments due  to  pain.  Not  infrequently  pleuritic  friction  may  be  heard 
altogether  below  the  level  of  the  lung. 

(6)  Pleuritic  Effusion. 

Many  cases  are  latent,  and  the  patients  consult  the  physician  on 
account  of  slight  cough,  weakness,  or  gastric  trouble,  so  that  the 
effusion  is  first  discovered  in  the  course  of  routine  physical  examina- 


316 


PHYSICAL  DIAGNOSIS 


tion.     Since  it  is  usually  the  results  of  percussion  which  first  put  us  on 
the  right  track,  I  shall  take  up  first 

Percussion. 

I.  A  small  effusion  first  shows  as  an  area  of  dulness 

(a)   Just  below  the  angle  of  the  scapula. 

(6)    In  the  left  axilla  between  the  fifth  and  the  eighth  rib. 

(c)  Obliterating  Traube's  semilunar  area  of  tympany;  or 

(d)  In  the  right  front  near  the  angle  made  by  the  cardiac  and 
hepatic  lines  of  dulness  (see  Fig.   195). 

In  the  routine  percussion  of  the  chest,  therefore,  one  should  never 
leave  out  these  areas.     A  small  effusion  is  most  easily  detected  in 


Area  of  dulness 
due  to  small 
pleural  effusion. 


--  Area  of  cardiac 
dulness. 


Fig.  195. — Small  Pleural  Effusion  Accumulating  (in  part)  near  the  Right  Border  of  the 

Heart. 


children  or  in  adults  with  thin  chest  walls,  provided  our  percussion  is 
not  too  heavy.  An  effusion  amounting  to  a  pint  should  always  be 
recognizable,  and  smaller  amounts  have  frequently  been  diagnosed 
and  proved  by  puncture. 

The  amount  of  a  pleuritic  effusion  is  roughly  proportional  to  the 
area  of  dulness  on  percussion,  but  not  accurately.  It  is  very  common 
to  find  on  puncture  an  amount  of  fluid  much  greater  than  could  have 
been  suspected  from  the  percussion  outlines;  on  the  other  hand,  the 
dulness  may  be  extensive  and  intense  on  account  of  great  inflamma- 
tory thickening  of  the  costal  pleura,  by  the  accumulation  of  layer  after 
layer  of  fibrinous  exudate  and  its  organization  into  fibrous  plates, 
while  very  little  fluid  remains  within. 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY 


317 


The  amount  of  dulness  depends  also  upon  the  thickness  and  elasti- 
city of  the  chest  wall  and  the  degree  of  collapse  of  the  lung  within. 

2.  Large  Effusions. — -When  the  amount  of  fluid  is  large,  the  dul- 
ness may  extend  throughout  the  whole  of  one  side  of  the  chest  with 
the  exception  of  a  small  area  above  the  clavicle  or  over  the  primary 
bronchus  in  front.  This  area  gives  a  high-pitched  tympanitic  note, 
provided  the  bronchi  remain  open,  as  they  almost  always  do.  This 
tympany  is  high-pitched  and  sometimes  astonishingly  clear.  I  re- 
cently saw  a  case  in  which  the  note  above  the  clavicle  was  almost 
indistinguishable  with  the  eyes  shut  from  that  obtained  in  the  epi- 
gastrium. Occasionally  "cracked-pot"  resonance  may  be  obtained 
in  the  tympanitic  area. 


Normol  resonance 
and  vesicular 
breathing. 


Tympany,  voice  and 
fremitus  increased. 


Flatness,  no  breath- 
ing, voice  sounds, 
or  fremitus. 


Zone  of  condensed 
lung  above  the 
fluid. 


Exaggerated  (com- 
pensatory) breath- 
ing and  reso- 
nance. 


Fig.  196. — Diagram  to  Illustrate  Physical  Signs  in  Moderate- Sized  Effusion  in  the  Left 

Pleura. 


The  pitch  changes  if  the  patient  opens  and  closes  his  mouth  while 
we  percuss  ("William's  tracheal  tone"). 

The  dulness  over  the  lower  portions  of  a  large  effusion  is  usually 
very  marked,  and  the  percussing  finger  feels  a  greatly  increased  resist- 
ance to  its  blows  when  compared  with  the  elastic  rebound  of  the 
sound  side. 

3.  Moderate  Effusions. — Three  zones  of  resonance  can  often  be 
mapped  out  in  the  back :  at  the  base  dulness  or  flatness,  above  that  a 
zone  of  mingled  dulness  and  tympany,  and  at  the  top  normal  reso- 
nance. The  lowest  zone  corresponds  to  the  fluid,  the  middle  zone  to 
the  condensed  lung  immediately  above  it,  and  the  top  zone  to  the 
relatively  unaffected  part  of  the  lung  (see  Fig.  196) .     Not  infrequently 


318  PHYSICAL  DIAGNOSIS 

there  is  no  middle  zone  but  simply  dulness  below  and  resonance  above, 
as  is  usually  the  case  in  the  axilla  and  front. 

The  position  of  the  effusion  depends  only  in  part  upon  the  influence 
of  gravity,  and  is  greatly  influenced  by  capillarity  and  the  degree  of 
retraction  of  the  lungs.  Consequently  the  surface  of  the  fluid  is 
hardly  ever  horizontal.  With  the  patient  in  an  upright  position  it 
usually  reaches  a  higher  level  in  the  axilla  than  in  the  back  (see  Fig. 
197).  Near  the  spine  and  near  the  sternum  (in  right-sided  effusions) 
the  line  corresponding  to  the  level  of  the  fluid  may  rise  sharply. 


Fig.  197. — Left  Pleural  Effusion.  Heart  displaced  to  right  of  sternum.  Note  that 
the  surface  of  the  fluid  slopes  outward  and  upward  from  the  median  line.  (From  v. 
Ziemssen's  Atlas.) 

There  is  rarely  any  information  of  value  to  be  obtained  by  trying  to 
elicit  a  change  in  the  percussion  note  with  change  in  the  patient's 
position.  First,  because  in  the  normal  chest  there  is  some  change  in 
the  percussion  note  if  we  try  it  first  with  the  patient  upright  and  then 
bending  forward.  Next,  because  even  in  known  pleural  effusion  it  has 
been  found  that  with  change  in  the  position  of  the  patient  the  level  of 
the  fluid  sometimes  changes  very  slowly  and  irregularly,  and  some- 
times does  not  change  at  all.  If,  for  purposes  of  thorough  examina- 
tion, we  raise  to  a  sitting  posture  a  patient  who  has  been  for  some  days 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY  319 

or  weeks  in  bed,  we  should  never  begin  the  examination  at  once,  since 
it  may  take  some  minutes  for  the  lungs  and  the  fluid  to  accommodate 
themselves  to  the  new  position.  It  is  well  also  to  get  the  patient  to 
cough  and  to  take  a  number  of  full  breaths  before  the  examination  is 
begun. 

Grocco's  (Koranyi's)  Sign — The  Paravertebral  Triangle. 

On  the  sound  side  in  the  position  shown  in  Fig.  196  (p.  317)  a 
triangular  patch  of  dulness  can  be  percussed  out  in  most  cases  of 
pleural  effusion.  The  voice  sound  and  breath  sounds  are  diminished 
over  this  triangular  area. 

I  have  not  found  this  sign  of  much  value  in  diagnosis.  One  can 
rarely  percuss  out  the  triangular  dull  area  with  any  confidence  unless 
one  previously  knows  that  there  is  an  effusion  on  the  other  side. 

When  the  fluid  is  absorbed  or  removed  by  tapping,  one  would 
expect  an  immediate  return  of  the  percussion  resonance.  But  in  fact 
the  resonance  returns  very  slowly  and  is  wholly  unreliable  as  a  test  of 
the  amount  of  absorption  which  has  occurred.  Thickened  pleura  and 
atelectatic  lung  may  abolish  resonance  long  after  the  fluid  is  all  gone. 
We  depend  here  far  more  upon  the  evidence  obtained  by  auscultation 
and  palpation  and  on  the  general  condition  of  the  patient. 

To  determine  the  returning  elasticity  of  the  lung  and  the  degree  of 
movability  of  its  lower  border,  percussion  is  very  useful  during  the 
stage  of  absorption.  After  percussing  out  the  lower  border  of  pul- 
monary resonance  in  the  back,  the  patient  is  directed  to  take  a  long 
breath  and  hold  it.  If  the  lung  expands,  the  area  of  percussion  reson- 
ance will  increase  downward. 

Percussion  aids  us  in  determining  whether  neighboring  organs  are 
displaced  by  the  pressure  of  the  accumulated  fluid.  The  liver  is  often 
pushed  down,  the  spleen  very  rarely.  Dislocation  of  the  heart  is  one  of 
the  most  important  of  all  the  signs  of  pleural  effusion,  and  is  often  the 
crucial  point  in  differential  diagnosis.  It  is  a  very  striking  and  at  first 
surprising  fact  that  a  left-sided  effusion  displaces  the  heart  far  more 
than  a  right-sided  effusion  of  the  same  size.  Small  or  moderate  right- 
sided  effusions  often  do  not  displace  the  heart  at  all. 

With  left-sided  effusions,  unless  very  small,  we  find  the  area  of 
cardiac  dulness  shifted  toward  the  right  and  often  projecting  beyond 
the  right  edge  of  the  sternum  (see  Fig.  197).  (Inspection  and  palpa- 
tion often  give  us  even  more  valuable  information  on  this  point.  See 
below,  p.  323.)     We  must  be  careful  to  distinguish  such  an  area  of 


320  PHYSICAL  DIAGNOSIS 

dulness  at  the  right  sternal  margin  from  that  which  may  be  produced 
in  right-sided  effusions  by  the  fluid  itself  (see  above) . 

As  mentioned  above,  a  right  pleural  effusion  may  very  early  show 
itself  as  an  area  of  dulness  along  the  right  sternal  margin.  Light 
percussion  will  usually  demonstrate  that  this  dulness  is  continuous 
with  a  narrow  strip  of  flatness  at  the  base  of  the  axilla  (ninth  and 
tenth  ribs).  Such  an  effusion  is  late  in  creeping  up  the  axilla.  It 
appears  first  and  disappears  first  along  the  right  margin  of  the  sternum. 

On  the  sound  side  the  percussion  resonance  is  often  increased, 
owing  to  compensatory  hypertrophy  of  the  sound  lung;  the  diaphragm 
is  pushed  down  and  the  borders  of  the  heart  or  of  the  liver  may  be 
encroached  upon.  When  the  hyper-resonance  of  the  sound  side  is 
present,  it  should  warn  us  to  percuss  lightly  over  the  effusion,  else  we 
may  bring  out  the  resonance  of  the  distended  lung. 

Summary  of  Percussion  Signs. — ( i )  Flatness  corresponding  roughly 
to  the  position  of  the  fluid. 

(2)  Tympany  above  the  level  of  the  fluid  over  the  condensed  lung. 

(3)  The  level  of  the  fluid  is  almost  never  horizontal. 

(4)  Shifting  of  the  fluid  with  change  of  position  is  rare,  slow,  and 
has  little  or  no  importance  in  diagnosis. 

Exceptions  and  Possible  Errors. — (a)  Great  muscular  pain  and 
spasm  may  produce  an  area  of  dulness  which  simulates  that  of  pleural 
effusions,  especially  as  the  auscultatory  signs  may  be  equally  mislead- 
ing. A  hypodermic  of  morphine  will  dispel  the  dulness  along  with  the 
pain  if  it  is  due  to  muscular  cramp. 

(6)  If  the  lung  on  the  affected  side  fails  to  retract  (owing  to 
emphysema  or  adhesions  to  the  chest  wall) ,  the  area  of  dulness  and  its 
intensity  will  be  much  diminished. 

(c)  It  must  be  remembered  that  dulness  in  Traube's  space  is  sel- 
dom of  significance  since  it  may  be  due  to  solidification  of  the  lung,  to 
situs  inversus,  to  tumors,  or  to  overfilling  of  the  stomach  and  intestine 
with  food,  as  well  as  to  pleural  effusion;  also  that  the  size  of  the  tym- 
panitic space  varies  greatly  in  health. 

{d)  Rarely  percussion  may  be  tympanitic  over  an  effusion  at  the 
left  base  owing  to  distention  of  the  stomach  or  colon. 

{e)  The  diagnosis  between  fluid  and  thickened  pleura  will  be 
considered  later. 

Auscultation. 

The  auscultatory  phenomena  vary  greatly  in  different  cases,  and 
in  the  same  case  at  different  times,  because  the  essential  conditions 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY  321 

are  subject  to  similar  variations.  Whatever  sounds  are  produced  in  the 
lungs  or  in  the  bronchi  may  be  heard  over  the  fluid  unless  interfered 
with  by  inflammatory  thickening  of  the  costal  pleura.  Fluid  transmits 
sounds  well,  but  there  may  be  no  breath  sounds  produced  and  hence  none 
audible  over  the  fluid.  Or  tubular  sounds  only  may  be  produced 
because  only  the  bronchi  remain  open,  the  rest  of  the  lung  being 
collapsed. 

Or  again,  if  rales  or  friction  sounds  are  produced  in  the  lung,  they, 
too,  may  be  transmitted  to  the  fluid  and  may  (alas!)  deter  the  timid 
"observer"  from  tapping. 

In  about  two-thirds  of  all  large  effusions  no  breathing  at  all  is 
audible  over  the  area  of  flatness  on  percussion.  In  the  remaining 
third,  and  especially  in  children,  tubular  breathing,  sometimes  feeble, 
sometimes  very  intense,  is  to  be  heard. 

In  moderate  effusions  there  are  often  three  zones  in  the  back.  At 
the  bottom  we  hear  nothing,  in  the  middle  zone  distant  bronchial  or 
broncho-vesicular  breathing,  while  at  the  summit  of  the  chest  the 
breathing  is  normal. 

The  voice  sounds  correspond.  When  breath  sounds  are  absent, 
the  voice  sounds  are  likewise  absent.  When  the  breathing  is  tubular, 
the  voice,  and  especially  the  whisper,  is  also  tubular  and  intensified. 
That  is,  whenever  the  bronchi  are  open,  the  lung  retracted,  and 
the  chest  walls  thin,  the  breathing,  voice,  and  whisper  will  correspond 
to  the  tracheal  sounds.  Since  children  have  especially  thin  chest 
walls,  these  bronchial  sounds  are  especially  frequent  and  intense  in 
children.^ 

Near  the  angle  of  the  scapula  and  in  a  corresponding  position  in 
front,  the  sound  of  the  spoken  voice  may  have  a  peculiar  high-pitched, 
nasal  twang,  to  which  the  term  egophony  is  applied.  This  sign  has  no 
importance  in  diagnosis,  since  it  is  not  constant,  and  not  peculiar  to 
fluid  accumulations. 

Rales  are  rarely  produced  in  the  retracted  lung,  and  so  are  rarely 
to  be  heard  over  the  fluid. 

All  these  sounds  may  be  diminished  or  abolished  if  the  costal  pleura 
is  greatly  thickened. 

The  influence  of  cough  upon  the  lung,  and  so  upon  the  sounds  pro- 
duced in  it  and  transmitted  through  the  fluid,  may  be  very  great  and 
very  puzzling.  Rales  may  appear  or  disappear,  breathing  change 
in  quality  or  intensity,  and  in  the  differential  diagnosis  of  difficult 

^Bacelli's  theory — that  the  whispered  voice  is  conducted  through  serum  but  not  through 
pus — is  not  borne  out  by  facts. 
21 


322 


PHYSICAL  DIAGNOSIS 


cases  the  patient  should  always  be  made  to  cough  and  then  breathe 
deeply  before  the  examination  is  completed. 

In  very  large  effusions,  when  only  the  primary  bronchi  are  open, 
there  may  be  signs  like  those  of  pulmonary  cavity  at  the  site  of  the 
bronchi  in  front  or  behind  (amphoric  breathing,  large  metallic  rales, 
etc.).  Over  the  sound  lung  the  breathing  is  exaggerated  and  extends 
unusually  far  down  in  the  back  and  axilla,  owing  to  hypertrophy  of  the 
lung. 


Fig.   198.  Interlobar   A,   A=Exudate 


The  heart  sounds  may  be  absent  at  the  apex  owing  to  dislocation 
of  the  heart.  In  left-sided  effusions  the  apex  sounds  are  often  loudest 
near  the  ensiform  cartilage  or  beyond  the  right  margin  of  the  sternum. 
Right-sided  effusions  have  much  less  effect  upon  the  heart,  but  occa- 
sionally we  find  the  heart  sounds  loudest  at  the  left  of  the  nipple  or  in 
the  axilla. 

Since  most  cases  of  pleural  effusion  are  due  to  tuberculosis,  we 
should  never  omit  to  search  for  evidences  of  this  disease  at  the  apex  of 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY  323 

the  lung  on  the  sound  side,  since  experience  has  shown  that  phthisis  is 
more  apt  to  begin  here  than  on  the  side  of  the  efifusion. 

Summary  of  Auscultatory  Signs. 

(i)  In  most  cases  voice  and  breath  sounds  are  absent  or  very 
feeble  over  the  area  occupied  by  the  fluid. 

(2)  In  a  minority  of  the  cases  the  breathing  and  voice  sounds  may 
be  tubular  and  intensified,  especially  in  children. 

(3)  Over  the  condensed  lung  at  the  summit  of  the  chest  the  breath- 
ing is  bronchial  or  broncho-vesicular,  according  to  the  degree  of  con- 
densation. If  the  amount  of  fluid  is  small,  the  layer  of  condensed 
lung  occupies  the  middle  zone  of  the  chest  and  the  breathing  is  normal 
at  the  top  of  the  chest. 

(4)  Rales  and  friction  sounds  are  rarely  heard  over  fluid. 

(5)  On  the  sound  side  the  breathing  is  exaggerated. 

(6)  The  heart  sounds  may  be  absent  at  the  apex  and  present  in  the 
left  axilla  or  to  the  right  of  the  sternum  owing  to  dislocation  of  the 
heart. 

Inspection  and  Palpation. 

The  most  important  information  given  us  by  inspection  and  palpa- 
tion relates  to  the  displacement  of  various  organs  by  the  pressure  of  the 
accumulated  fluid.  In  left-sided  pleuritic  effusions  the  heart  is  usually 
displaced  considerably  toward  the  right,  even  when  the  level  of  the 
fluid  reaches  no  higher  than  the  sixth  rib  in  the  nipple  line.  The  im- 
pulse is  then  to  be  seen  and  felt  to  the  right  of  the  sternum,  somewhere 
between  the  third  and  the  seventh  rib,  when  a  large  amount  of  fluid  is 
present.  With  smaller  effusions  one  may  find  the  apex  beat  lifting  the 
sternum  or  close  to  its  left  border.  The  position  of  the  heart  may  be 
confirmed  by  percussion. 

The  spleen  is  scarcely  ever  displaced. 

Right-sided  effusions  are  far  less  likely  to  displace  the  heart,  and  it 
is  only  when  a  large  amount  of  fluid  is  present  that  the  apex  of  the 
heart  is  pushed  outward  beyond  the  nipple.  Moderate  right-sided 
effusions  often  produce  no  dislocation  of  the  heart  whatever.  The 
liver  may  be  considerably  pushed  down  by  a  right-sided  pleuritic  effu- 
sion, and  its  edge  may  be  palpable  several  inches  below  the  costal 
margin.  Its  upper  margin  cannot  be  determined  by  percussion,  as  it 
merges  into  the  flatness  produced  by  the  fluid  accumulation  above  it. 


324  PHYSICAL  DIAGNOSIS 

Tactile  fremitus  is  almost  invariably  absent  or  greatly  diminished 
over  the  areas  corresponding  to  the  fluid;  just  above  the  level  of  the 
fluid  it  is  often  increased. 

Occasionally  a  slight  fulness  of  the  affected  side  may  be  recognized 
by  inspection,  and  the  interspaces  may  be  less  readily  visible  than  upon 
the  sound  side.  Bulging  of  the  interspaces  I  have  never  observed. 
When  the  accumulation  of  fluid  is  large  the  respiratory  movements 
upon  the  affected  side  are  somewhat  diminished,  ^  the  shoulder  is  raised, 
and  the  spine  curved  toward  the  affected  side.  The  diaphragm  is 
depressed,  and  Litten's  sign  therefore  absent. 

There  are  no  reliable  physical  signs  for  distinguishing  purulent  from 
serous  effusions.  The  whispered  voice  may  be  transmitted  through 
either  pus  or  serum.  But  we  know  that  in  children  two-thirds  of  all 
effusions  are  purulent,  while  in  adults  three-fourths  of  them  are 
serous.  The  presence  of  leucocytosis  in  empyema  and  its  absence 
in  most  cases  of  serous  {i.e.,  tuberculous)  pleurisy  is  of  more  value 
in    diagnosis. 

Physical  Signs  During  Absorption  of  Pleural  Effusions. 

When  the  fluid  begins  to  disappear,  either  spontaneously  or  as  a 
result  of  treatment,  the  dulness  very  gradually  disappears  and  the 
breath  sounds,  voice  sounds,  and  fremitus  reappear.  In  case  the 
heart  has  been  dislocated,  its  return  to  its  normal  position  is  often  much 
slower  than  one  would  anticipate,  and  indeed  all  the  physical  signs  are 
disappointingly  slow  to  clear  up  even  after  tapping.  Pleural  friction 
appears  when  the  roughened  pleural  surfaces,  which  have  been  held 
apart  by  the  fluid,  are  allowed  by  the  disappearance  of  the  latter 
to  come  into  apposition  again.  Owing  to  pulmonary  atelectasis  and 
permanent  thickening  of  the  pleura,  considerable  dulness  often 
remains  for  weeks  after  the  fluid  has  been  absorbed.  One  need  not 
be  disappointed  or  believe  that  the  fluid  has  again  accumulated  if 
one  finds  but  little  change  in  the  physical  signs  during  the  first  week 
after  tapping.     A  second  puncture  rarely  shows  fluid. 

Interlobar  Empyema. 

In  recent  years  the  frequency  and  importance  of  empyema  lim- 
ited   to    an  interlobar    fissure    has    become  impressed    upon    many 

'  I  have  purposely  made  but  little  of  the  changes  in  the  shape  of  the  chest  produced 
by  pleuritic  effusions,  as  it  has  seemed  to  me  that  by  far  too  much  stress  has  usually  been 
laid  upon  such  signs. 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY 


325 


clinicians.  I  have  seen  both  the  post-pneumonic  and  the  tuberculous 
types,  but  the  former  is  much  the  commoner.  In  most  of  the  cases 
so  far  reported  the  pus  has  been  demonstrated  in  the  fissure  which 
runs  along  the  vertebral  border  of  the  scapula  when  that  bone  is 
pulled  as  far  forward  as  possible  by  crossing  the  arms  in  front 
(see  Fig.  199). 

This  is  a  region  seldom  carefully  examined. 

In  the  strip  here  indicated  one  finds  flatness  on  percussion  with 
(usually)   diminished  fremitus,   and  feeble  or  absent  breath-sounds. 


Compressed  areas  of 
lung,  showing  in- 
tense tubular 
breathing  and 
whisper  with  dul- 
ness. 


Flatness. 
Diminished  or  absent 

breathing. 
Diminished  or  absent 

voice. 


Fig.  199. — Signs  in  Interlobar  Empyema. 

X-ray  examination  may  bring  out  in  sharp  relief  a  shadow  corres- 
ponding to  this  area  and  sharply  contrasted  with  the  relatively 
normal  lung  above  and  below  it. 

The  exploring  needle  often  fails  to  find  the  pus,  but  the  search 
should  not  be  given  up  (if  the  physical  signs  are  clear)  until  a  rib  has 
been  excised  and  the  region  thoroughly  explored  under  complete 
anaesthesia.  Empyema  encysted  between  the  diaphragm  and  lung  or 
between  the  lung  and  chest  wall  are  not  uncommon  but  can  rarely  be 
diagnosed. 

(c)  Pleural  Thickening. 

In  persons  who  have  previously  suffered  from  pleurisy  with 
effusion,  and  in  many  who  have  never  to  their  knowledge  had  any 
such  trouble,  a  considerable  thickening  of  the  pleural  membrane  with 
adhesion  of  the  costal  and  visceral  layers  may  be  manifested  by  the 
following  signs: 


326  PHYSICAL  DIAGNOSIS 

(i)   Dulness  on  percussion,  sometimes  slight,  sometimes  marked. 

(2)  Diminished  vesicular  respiration. 

(3)  Voice  sounds  and  tactile  fremitus  diminished  or  increased. 

(4)  Absence  of  Litten's  phenomenon  and  diminution  in  the  normal 
respiratory  excursion  of  the  chest. 

These  signs  are  most  apt  to  be  found  at  the  base  of  the  lung  be- 
hind and  in  the  axilla.  Occasionally  a  similar  thickening  may  be 
demonstrated  throughout  the  whole  extent  of  the  pleura,  and  the 
lung  failing  to  expand,  the  chest  may  fall  in  as  a  result  of  atmospheric 
pressure  (see  Fig.  73). 

The  ribs  approximate  and  may  overlap,  the  spine  becomes  curved, 
the  shoulder  lowered,  the  scapula  prominent,  and  the  whole  side 
shrunken.     The  heart  may  be  drawn  over  toward  the  affected  side. 

In  the  diagnosis  of  pleural  thickening  Rosenbach's  "palpatory 
puncture"  is  sometimes  our  only  resource.  Under  antiseptic  pre- 
cautions a  hollow  needle  is  pushed  between  the  ribs  and  into  the 
pleural  cavity.  As  the  needle  forces  its  way  through  the  tough  fibrous, 
or  perhaps  calcified,  pleura,  the  degree  and  kind  of  resistance  are  very 
enlightening.  Again,  the  amount  of  mobility  of  the  point  after  the 
chest  wall  has  been  pierced  tells  us  whether  the  needle  is  free  in  a 
cavity,  entangled  in  a  nest  of  adhesions,  or  fixed  in  a  solid  "  carnified" 
lung.     There  is  no  danger  if  the  needle  is  sterile. 

Encapsulated  Pleural  Effusion. 

Small  accumulations  of  serum  or  pus  may  be  walled  off  by  adhe- 
sions so  that  the  fluid  does  not  gravitate  to  the  lowest  part  of  the 
pleural  cavity  or  spread  itself  laterally  as  it  would  if  free.  Such 
localized  effusions  are  not  uncommon.  Thirty-one  per  cent  of  thirty- 
eight  empyemata  autopsies  at  the  Massachusetts  General  Hospital 
were  encapsulated.  They  are  most  apt  to  be  found  in  the  lower 
axillary  regions  or  behind — sometimes  between  the  base  of  the  lung 
and  the  diaphragm,  and  more  often  between  the  lobes  of  one  of  the 
lungs  or  higher  up.  The  position  of  the  fluid  may  be  almost  vertical, 
lying  in  a  shallow  pool  along  the  axillary  ribs  or  near  the  spinal  column. 
I  have  twice  seen  an  encapsulated  purulent  effusion  so  close  to  the 
left  margin  of  the  heart  that  the  diagnosis  of  pericardial  effusion  was 
made. 

The  diagnosis  of  encapsulated  pleural  effusion  is  a  difficult  one  and 
oftentimes  cannot  be  made  except  by  puncture.  The  signs  are  those 
of  fluid  in  the  pleura,  but  anomalously  placed.     Even  puncture  may 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY  327 

fail  to  clear  up  the  difificulty,  since  the  needle  may  pass  entirely 
through  the  pouch  of  fluid  and  into  some  structure  behind  so  that  no 
fluid  is  obtained. 

Pulsating  Pleurisy. 

Under  conditions  not  altogether  understood  the  movements  trans- 
mitted by  the  heart  to  a  pleural  effusion  (usually  purulent)  may  be 
visible  externally  as  a  circumscribed  pulsating  swelling  near  the 
precordial  region,  or  as  a  diffuse  undulation  of  a  considerable  portion 
of  the  chest  wall.  Sometimes  this  pulsation  is  visible  because  the 
fluid  has  worked  its  way  out  through  the  thoracic  wall  and  is  covered 
only  by  the  skin  and  subcutaneous  tissues,  but  occasionally  pulsation 
in  a  pleural  effusion  becomes  visible,  although  no  such  perforation  of 
the  chest  wall  has  occurred. 

The  condition  is  a  rare  one  (only  12  cases  are  on  record),  and  is  of 
importance  only  because  it  may  be  mistaken  for  an  aneurism,  from 
which,  however,  it  should  be  readily  distinguished  by  the  absence  of  a 
palpable  thrill  or  diastolic  shock  and  by  the  evidence  of  fluid  in  the 
pleura. 

Differential  Diagnosis  of  Pleuritic  Effusion. 

The  following  conditions  are  not  infrequently  mistaken  for  pleuritic 
effusion : 

(i)   Croupous  pneumonia  with  occlusion  of  the  bronchi. 

(2)  Pleura  thickening,  with  pulmonary  atelectasis. 

(3)  Subdiaphragmatic  abscess  or  abscess  of  the  liver. 

In  croupous  pneumonia  with  plugging  of  the  bronchi  one  may 
have  present  all  the  physical  signs  of  pleuritic  effusion  except  dis- 
placement of  the  neighboring  organs.  The  presence  or  absence  of  such 
displacement,  together  with  the  history,  symptoms,  and  course  of  the 
case,  is  therefore  our  mainstay  in  distinguishing  the  two  diseases. 

From  ordinary  croupous  pneumonia  (without  occlusion  of  the 
bronchi)  pleuritic  effusion  differs  in  that  it  produces  a  greater  degree  of 
dulness  and  a  diminution  of  the  spoken  voice  sounds  and  tactile 
fremitus.  Bronchial  breathing  and  bronchial  whisper  may  be  heard 
either  over  solid  lung  or  over  fluid  accumulation,  although  the  bron- 
chial sounds  are  usually  feeble  and  distant  in  the  latter  condition.  The 
displacement  of  the  neighboring  organs  is  of  importance  here  as  in  all 
diagnoses  in  which  pleuritic  effusion  is  a  possibility.  A  few  hard 
coughs  may  open  up  an  occluded  bronchus  and  so  clear  up  the  diagnosis 


328 


PHYSICAL  DIAGNOSIS 


at  once.  In  doubtful  cases  the  patient  should  always  be  made  to 
cough  and  breathe  deeply  before  the  examination  is  finished. 

It  should  always  be  remembered  that  one  may  have  both  pneu- 
monia and  pleuritic  effusion  at  the  same  time,  and  that  pneumonia  is 
often  accompanied  by  a  serous  or  followed  by  a  purulent  effusion.  In 
children  the  bronchi  are  especially  prone  to  become  occluded  even  as  a 
result  of  a  simple  bronchitis,  and  we  must  then  differentiate  between 
atelectasis  and  effusion — in  the  main  by  the  use  of  the  criteria  just 
described. 

(2)  It  is  sometimes  almost  impossible  to  distinguish  small  fluid 
accumulations  in  the  pleural  cavity  from  pleural  thickening  with 
pulmonary  atelectasis.  In  both  conditions  one  finds  dulness,  diminu- 
tion of  the  voice  sounds,  respiration,  and  tactile  fremitus,  and  absence 


Fig.  200. — Area  of  Dulness  in  Solitary  (tropical)  Abscess  of  the  Liver. 

of  Litten's  phenomenon,  but  the  tactile  fremitus  is  usually  more 
diminished  when  fluid  is  present  than  in  simple  pleural  thickening  and 
atelectasis.  The  presence  of  friction  sounds  over  the  suspected  area 
speaks  strongly  in  favor  of  pleural  thickening,  but  it  is  possible  to  hear 
friction  sounds  over  fluid,  probably  because  they  are  conducted  from 
a  point  higher  up  in  the  chest  at  which  no  fluid  is  present.  In  doubtful 
cases  the  diagnosis  can  and  should  be  cleared  up  by  puncture. 

(3)  In  two  cases  I  have  known  enlargement  of  the  liver  due  to 
multiple  abscesses  to  be  mistaken  for  empyema.  In  both  conditions, 
one  finds  in  the  right  back  dulness  on  percussion  as  high  as  mid-scapula, 
with  absence  of  voice  sounds,  breath  sounds,  and  fremitus.  These 
conditions  are  due  in  one  case  to  the  presence  of  fluid  between  the 
lung  and  the  chest  wall,  and  in  the  other  case  to  the  liver  which  pushes 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY  329 

Up  the  lung  together  with  the  diaphragm.  Without  the  fluoroscope  or 
a  good  radiograph  this  diagnosis  may  be  impossible.  With  the  fluoro- 
scope it  should  be  possible  to  see  that  the  dome  of  the  diaphragm  caps 
the  shadow  and  moves  down  with  it  during  inspiration.  Some  of  the 
symptoms,  such  as  chills,  sweating,  and  irregular  fever,  are  common  to 
both  conditions.  A  careful  consideration  of  the  history  and  the  associ- 
ated signs  and  symptoms  may  help  us  to  decide. 

Large  solitary  abscess  of  the  liver,  occurring  as  it  almost  invariably 
does  in  the  posterior  portions  of  the  right  lobe,  produces  an  area  of 
flatness  on  percussion,  which  rises  to  a  much  higher  level  in  the  axilla 
and  back  than  in  front  or  near  the  sternum  (see  Fig.  200) ,  and  may  be 
in  this  way  distinguished  from  empyema ;  but  when  the  liver  contains 
many  small  abscesses,  as  in  suppurative  cholangitis,  this  peculiar  line 
of  dulness  is  not  present. 

4.  Rare  diseases,  such  as  cancer  or  hydatid  of  the  lung,  may  be 
mistaken  for  pleuritic  effusion.  The  history  of  the  case  and  the  results 
of  exploratory  puncture  usually  clear  up  the  difficulty. 

Carcinoma  of  the  Pleura  (Endothelioma). 

About  fifty  cases  are  on  record.  Probably  many  are  falsely  diag- 
nosed as  a  chronic  rapidly  refilling  pleural  effusion.  The  fluid  obtained 
by  tapping  is  usually  bloody  either  from  the  first  or  later,  and  con- 
tains a  larger  proportion  of  endothelial  plaques  and  a  smaller  propor- 
tion of  lymphocytes  than  is  usual  in  chronic  pleurisy.  The  cells 
themselves,  however,  are  not  characteristic  of  a  neoplasm. 

The  physical  signs  in  the  chest  do  not  differ  from  those  of  any 
ordinary  pleural  effusion.  The  points  of  differential  diagnostic  value 
are: 

1.  The  presence  of  bloody  fluid  with  any  endothelial  sediment. 

2.  Its  rapid  and  repeated  reaccumulation. 

3.  Metastases  (supraclavicular,  axillary,  pectoral)  and  along  the 
needle-track. 

Similar  signs  are  obtained  in  the  rare  sarcoma  of  the  pleura  (four- 
teen cases  on  record) . 

Echinococcus  of  the  Pleura. 

This  disease  is  almost  unknown  in  North  America.  Forty-three 
foreign  cases  are  on  record.  The  signs  are:  those  of  encysted  pleural 
fluid  with  eosinophiles  and  booklets  in  the  tap  fluid,  which  is  remark- 
able in  that  it  does  not  contain  albumen  in  any  considerable  quantity. 
Urticaria  often  follows  puncture. 


330  PHYSICAL  DIAGNOSIS 

ActinoTYiycosis  of  the  Pleura. 

There  are  no  characteristic  physical  signs.  These  diseases  may  be 
suspected  if  an  empyema  perforates  the  chest  or  is  associated  with 
chronic  pulmonary  suppurating.  Diagnosis  depends  on  the  micro- 
scopic examination  of  the  fluid. 

Examination  of  Exudates  and  Transudates. 

Only  such  methods  as  can  be  carried  out  without  a  thermostat 
will  be  here  described.  Hence  the  examination  of  diphtheria  swabs, 
blood  cultures,  and  pus  are  excluded.     We  have  left  the  fluids  obtained 


• 


Fig.    20I. — Lymphocytosis    in    Pleural    Fluid.     Primary    tuberculous    pleurisy.     (X750 

diameters.)      (Musgrave.) 

by  tapping  the  pleura,  the  peritoneum,  and  the  spinal  cord.  The 
first  is  the  most  important. 

Pleural  Fluids. — A  fluid  withdrawn  from  the  pleura  by  puncture 
may  be  a  mechanical  transudate  (hydro thorax) ,  may  be  evidence  of 
tuberculous  pleurisy  (primary  or  associated  with  phthisis),  or,  rarely, 
an  exudate  of  septic  or  cancerous  origin. 

To  investigate  these  fluids  we  note : 

I.  Color.  Bloody  fluids  suggest  cancer,  but  occasionally  occur  in 
pneumonia  and  tuberculosis. 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY  331 

2.  Weight.^  Dropsical  fluid  is  generally  below  1.015  in  specific 
gravity.  Exuates  are  usually  in  the  vicinity  of  1.020.  An  ordinary 
specific-gravity  bulb  is  used. 

3.  The  cells  of  the  sediment  (cytodiagnosis) . 

Technique  of  Cytodiagnosis. — i.  Pour  fluid  into  tubes  of  a  cen- 
trifuge and  centrifugalize  five  minutes. 


9i 


Jf'' 


Fig.  202. — Polynuclears  and  Large  Lymphocytes  in  Pleural  Fluid  from  a  Case  of  Trau- 
matic Acute  Infectious  Pleurisy.     (X  750  diameters.)     (Musgrave.) 

2.  Pour  off  the  supernatant  fluid  and  stir  up  the  sediment  with 
a  platinum  loop,  so  as  to  suspend  the  sediment  in  the  few  remaining 
drops. 

3.  Spread  a  drop  of  the  mixture  on  a  clea^i  cover  glass  with  the 
platinum  loop  and  let  the  smear  dry  without  heating  it. 

4.  Stain  like  a  blood  film  (see  'below,  page  441)  with  the  following 
mixture :2  Wright's  modification  of  Leishman's  stain,  3  parts;  pure 
methyl  alcohol,  i  part. 

5.  After  staining,  wash  very  gently,  using  a  dropper  (else  the  whole 
film  may  be  pushed  off) ,  and  dry  in  the  fingers  over  a  Bunsen  or  alco- 
holic flame.     Do  not  blot  the  preparation. 

6.  Mount  in  Canada  balsam  and  examine  with  an  oil-immersion  lens. 
Interpretation  of  Results. — (a)    In  tuberculous  pleurisy,  lymphocytes 

1  The  amount  of  albumin  usually  runs  parallel  with  the  weight  of  the  fluid. 

-  Suggested  by  Musgrave:  Boston  Med.  and  Surg.  Journ.,  vol.  cli.,  p.  319,  1904. 


332 


PHYSICAL  DIAGNOSIS 


make  up  from  seventy  to  ninety-nine  per  cent — usually  over  ninety 
per  cent — of  all  the  cells  found  in  the  smear ^  (see  Fig.  201). 

(6)  In  septic  cases  due  to  the  streptococcus,  staphylococcus,  or 
pneumococcus  the  majority  of  the  cells  are  polynuclear  leucocytes 
(see  Fig.  202). 

(c)  In  transudations  (dropsical)  the  predominating  cell  is  a  large 
mononuclear  type,  apparently  endothelial  in  origin  and  often  occur- 
ring in  sheets  or  "plaques"  (see  Fig.  203). 


Fig.  203. — Pleural  Fluid  in  Hydrothorax  due  to  Cardiac  Disease.     Endothelial  plaques 
and  cells.     (X  750  diameters.)     (Musgrave.) 

Exceptions  occasionally  occur,  but  in  the  main  these  rules  are 
sufficiently  exact  to  be  of  value  in  diagnosis  when  taken  in  connection 
with  all  the  facts  in  the  case. 

In  peritoneal  fluid  the  use  of  cytodiagnosis  has  not  as  yet  furnished 
information  of  any  considerable  diagnostic  value. 

In  cerebrospinal  fluid  obtained  by  lumbar  puncture  the  predom- 
inance of  lymphocytes  is  not  so  often  associated  with  tuberculosis  as 
it  is  in  the  pleura,  but  usually  means  chronic  cerebrospinal  irritation 
such  as  is  produced  by  dementia  paralytica  and  tabes.  As  excess  of 
polynuclear  cells  is  usually  due  to  acute  meningitis, — epidemic  or 
sporadic. 

^  This  rule,  however,  does  not  work  both  ways.  Tuberculosis  produces  lymphocytosis, 
but  so  do  other  chronic  irritations.  The  lymphocytosis  is  a  mark  of  chroniciiy  and  only 
suggests  tuberculosis,  but  there  are  no  other  common  causes  for  chronic  pleural  irritation. 


CHAPTER  XVIII. 

ABSCESS,    GANGRENE,    AND    CANCER   OF    THE 

LUNG,  PULMONARY  ATELECTASIS,  (EDEMA, 

AND  HYPOSTATIC  CONGESTION. 

Abscess  and  Gangrene  of  the  Lung. 

I  consider  these  two  affections  together  because  the  physical  signs, 
exclusive  of  the  sputa,  do  not  differ  materially  in  the  two  affections. 
In  some  cases  there  may  be  no  physical  signs  at  all,  and  the  diagnosis  is 
made  from  the  character  of  sputa  and  from  a  knowledge  of  the  etiology 
and  symptomatology  of  the  case.  Lobar  pneumonia,  inhalation  of 
foreign  bodies  and  suppuration  elsewhere  are  the  commonest  causes. 
The  symptoms  are  of  sepsis  with  cough  and  purulent,  foul,  sometimes 
bloody  sputa,  containing  elastic  tissue.  In  most  cases  we  find  nothing 
more  than  a  patch  of  coarse  rales  or  a  small  area  of  solidification,  over 
which  distant  bronchial  breathing,  with  increased  voice  sound  and 
fremitus,  may  be  appreciated.  Usually  there  is  some  localized  dulness 
on  percussion.  One  may  find  the  signs  of  cavity  (amphoric  breathing, 
cracked-pot  resonance,  and  gurgling  rales),  but  this  is  unusual. 

Gangrene  of  the  lung  is  not  a  common  disease.  The  diagnosis 
usually  rests  altogether  upon  the  smell  and  appearance  of  the  sputa. 
In  fetid  bronchitis  one  may  have  sputa  of  equal  foulness,  but  the  odor  is 
different.  The  finding  of  elastic  tissue  in  the  sputa  proves  the  exist- 
ence of  something  more  than  bronchitis.  X-ray  examination  may 
help  in  diagnosis.  Often  it  reveals  areas  other  than  those  previously 
suspected. 

Pulmonary  abscess,  which,  like  gangrene,  is  a  rare  affection,  is 
often  simulated  by  the  breaking  of  an  empyema  into  the  lung  and  the 
emptying  of  the  pus  through  a  bronchus.  Large  quantities  of  pus  are 
expectorated  in  such  a  condition,  and  abscess  of  the  lung  is  suggested, 
but  the  other  physical  signs  are  those  of  empyema  and  should  be  easily 
recognized  as  such.  The  finding  of  elastic  fibres  is  the  crucial  point  in 
the  diagnosis  of  intrapulmonary  abscess,  whether  due  to  the  tubercle 
bacillus  or  to  other  organisms.  Tuberculous  abscess  (cavity)  is  usually 
near  the  summit  of  the  lung,  and  other  varieties  of  abscess  are  near 
the  base,  but  often  there  are  no  physical  signs  by  which  we  can 
distinctly  localize  the  process. 

333 


334  PHYSICAL  DIAGNOSIS 

Neoplasms  of  the  Lung    and  Mediastinum. 

(a)  Neoplasms  of  the  lung  are  usually  secondary  to  tumors  of  the 
digestive  tract,  bones,  uterus  or  breast,  and  are  recognized  chiefly  by  the 
presence  of  ill-defined  pulmonary  symptoms  in  patients  known  to  have 
previously  suffered  from  neoplasms  elsewhere  in  the  body. 

Primary  neoplasms  may  be  quite  without  physical  signs  or  may 
present  some  of  those  of  solidification  not  explained  by  any  of  the 
ordinary  causes.  Fremitus  is  often  absent.  Pleural  effusion  may 
overshadow  all  other  signs.  Supraclavicular  or  axillary  metastases 
may  put  us  on  the  right  track  or  if  the  superior  cava  or  its  branches  are 
compressed  by  glandular  metastases,  the  resulting  venous  distension 
and  oedema  is  suggestive. 

Mediastinal  Neoplasms. 

According  to  Christian^  the  mediastinal  neoplasms  which  are 
neither  so  rare  nor  so  obscure  as  to  make  diagnosis  practically  impos- 
sible are:  (i)  Sarcoma  (including  lymphosarcoma,  leucaemic  growths, 
and  Hodgkins'  disease;  (2)   Teratoma  and  cyst. 

Mediastinal  Sarcoma. 

Starting  in  the  local  lymph  nodes,  in  the  thymus  or  in  the  connec- 
tive tissue,  occurring  at  any  age  and  chiefly  in  males,  the  growths  com- 
prise neighboring  structures  and  thus  produce  dyspnoea,  cough,  and 
pain,  sometimes  dysphagia  and  hoarseness. 

The  physical  signs  are:  (a)  prominence  or  bulging  of  the  regions 
near  the  manubrium ;  (b)  distension  of  the  veins  of  the  neck  and  upper 
thorax,  cyanosis  and  localized  oedema  from  pressure  on  the  cava  or  its 
branches;  (c)  metastatic  tumors  in  the  neck  which  may  push  the 
trachea  to  one  side;  (d)  percussion  dulness  on  each  side  of  the  manu- 
brium with  diminished  vocal  and  tactile  fremitus.  Auscultation  rarely 
yields  characteristic  results,  though  there  may  be  noisy  strident  breath- 
sound  from  pressure  on  a  bronchus,  (e)  Evidence  of  pleural  effusion. 
(f)   X-ray  shadows  of  characteristic  irregular  shape. 

Differential  Diagnosis. 

Our  chief  business  is  to  exclude  aneurism.  This  is  usually  possible 
by  studying  the  shape  of  the  x-ray  shadow,  the  course  and  history 
of  the  case,  the  Wassermann  reaction,  and  the  pressure  symptoms 

^Christian:  Osier's  Modern  Medicine,  vol.  iii,  p.  893. 


ATELECTASIS  335 

which  with  tumors  are  far  more  apt  to  include  venous  distension, 
oedema,  and  cyanosis  than  is  the  case  with  aneurism  (see  also  p.  272). 
Tumors  of  the  lung  itself  may  produce  mediastinal  metastases,  and 
are  then  indistinguishable  from  primary  mediastinal  disease. 

Cysts  of  the  Mediastinum. 

Christian  (loc.  cit.)  has  collected  sixty-four  cases  of  dermoid  cyst  or 
teratoma  of  the  mediastinum.  Most  cases  occur  before  the  thirtieth 
year.  The  course  is  very  chronic.  The  cyst  may  exist  for  years  with- 
out producing  any  symptoms  and  then  be  accidentally  discovered  in 
the  course  of  an  :r-ray  examination  undertaken  for  some  other  pur- 
pose. When  it  grows  large  enough  to  produce  pressure  symptoms  it 
may  give  rise  to  dyspnoea,  pain,  and  cough.  In  eleven  of  Christian's 
cases  hair  was  expectorated  as  a  result  of  communication  between  the 
cyst  and  a  bronchus.  Bulging  of  the  chest  wall  near  the  manubrium 
with  dulness  on  percussion,  diminished  breathing,  and  vocal  sounds, 
and  an  often  characteristically  spherical  ovoid  :r-ray  shadow,  are  the 
most  constant  physical  signs. 

Atelectasis. 

(a)  Areas  of  atelectasis  or  collapse  of  pulmonary  tissue  are  often 
present  in  connection  with  various  pathological  processes  in  the  lung 
(such  as  tuberculosis  or  lobular  pneumonia) ,  but  are  usually  too  small 
to  give  rise  to  any  characteristic  physical  signs;  nevertheless 

(6)  In  most  normal  individuals  a  certain  degree  of  atelectasis  of 
the  margins  of  the  lungs  may  be  demonstrated  in  the  following  way: 
The  position  of  the  margins  of  the  lungs  in  the  axillae,  in  the  back,  or  in 
the  precordial  region  are  marked  out  by  percussion  at  the  end  of 
expiration.  The  patient  is  then  directed  to  take  ten  full  breaths,  and 
the  pulmonary  outlines  at  the  end  of  expiration  are  then  percussed  out 
a  second  time.  The  pulmonary  resonance  will  now  be  found  to  extend 
nearly  an  inch  beyond  its  former  limits,  owing  to  the  distention  of 
previously  collapsed  air  vesicles. 

If  one  auscults  the  suspected  areas  during  the  deep  breaths  which 
are  used  to  dispel  the  atelectasis,  very  fine  rales  are  often  to  be  heard 
at  the  end  of  expiration,  disappearing  after  a  few  breaths  in  most  cases, 
but  sometimes  audible  as  long  as  we  choose  to  listen  to  them.  These 
sounds,  to  which  Abrams  has  given  the  name  of  "atelectatic  crepita- 
tion," are  in  my  experience  especially  frequent  at  the  base  of  either 


336  PHYSICAL  DIAGNOSIS 

axilla.  The  same  writer  has  noticed  an  opacity  to  the  x-rays  over 
such  atelectatic  areas. 

Forcible  percussion  may  be  sufficient  to  distend  small  areas  of 
collapsed  lung,  or  at  any  rate  to  dispel  the  dulness  previously  present 
(see  above,  p.  135,  the  lung  reflex). 

(c)  When  one  of  the  large  bronchi  is  compressed  (as  by  an  aneu- 
rism) or  occluded  by  a  foreign  body,  collapse  of  the  corresponding  area 
of  lung  may  be  shown  by  diminished  motion  of  the  affected  side, 
dulness  on  percussion,  and  absence  of  breathing,  voice  sounds,  and 
tactile  fremitus. 

In  new-born  babies  whose  lungs  do  not  fully  expand  at  the  time 
of  birth,  similar  physical  signs  are  present  over  the  non-expanded 
lobes.     The  right  lung  is  especially  apt  to  be  affected. 

In  the  differential  diagnosis  of  extensive  pulmonary  collapse,  the 
etiology,  the  suddenness  of  the  onset,  the  absence  of  fever  and  of 
displacement  of  neighboring  organs  enable  us  to  exclude  pneumonia 
and  pleuritic  effusion.  In  distinguishing  small  areas  of  solidification 
from  similar  areas  of  atelectasis,  Abrams  finds  the  "lung-reflex"  (see 
page  135)  of  value.  Atelectatic  areas  expand  if  the  skin  overlying 
them  is  irritated.     Solidified  areas  show  no  change. 

(Edema  of  the  Lungs. 

In  cardiac  or  renal  disease  one  can  often  demonstrate  that  the 
lungs  have  been  invaded  by  transuded  serum  as  a  part  of  the  general 
dropsy.  More  rarely  pulmonary  oedema  exists  without  much  evidence 
of  oedema  in  other  organs  or  tissues. 

The  only  physical  sign  characteristic  of  this  condition  is  the 
presence  of  numerous  rales  in  the  dependent  portions  of  the  lungs; 
that  is,  throughout  their  posterior  surfaces  when  the  patient  has  been 
for  some  time  in  a  recumbent  position;  or  over  the  lower  portions  of 
the  axillae  and  the  back  if  the  patient  has  not  taken  to  his  bed. 

The  rales  are  always  bilateral  (unless  the  patient  has  been  lying  for 
a  long  time  on  one  side) ,  and  the  individual  bubbles  appear  to  be  all  of 
the  same  size,  or  nearly  so,  differing  in  this  respect  from  those  to  be 
heard  in  bronchitis.  Squeaking  or  groaning  sounds  are  less  often 
heard.  The  respiratory  murmur  is  usually  somewhat  diminished  in 
intensity. 

Dulness  on  percussion  and  modification  of  voice  sounds  are  not 
present,  unless  hydrothorax  or  hypostatic  pneumonia  complicate  the 
oedema. 


HYPOSTATIC  PNEUMONIA  337 

Hypostatic  Pneumonia. 

In  long,  debilitating  illness,  such  as  typhoid  fever,  the  alveoli  of  the 
dependent  portions  of  the  lungs  may  become  so  engorged  with  blood 
and  alveolar  cells  as  to  be  practically  solidified.  Under  these  condi- 
tions examination  of  the  posterior  portions  of  the  lungs  shows  usually : 

(a)  Slight  dulness  on  percussion  reaching  usually  from  the  base  to 
a  point  about  one-third  way  up  the  scapula.  At  the  very  base  the 
dulness  is  less  marked  and  becomes  mixed  with  a  shade  of  tympany. 

(b)  Feeble  or  absent  tactile  fremitus. 

(c)  Diminished  or  suppressed  breathing  and  voice  sounds. 

The  right  lung  is  apt  to  be  more  extensively  affected  than  the  left. 

Occasionally  the  breathing  is  tubular  and  the  voice  sounds  are  in- 
creased, making  the  physical  signs  identical  with  those  of  croupous 
pneumonia,  but  as  a  rule  the  bronchi  are  as  much  engorged  as  the  alve- 
oli to  which  they  lead,  and  hence  no  breath  sounds  are  produced. 

Rales  of  oedema  or  of  bronchitis  may  be  present  in  the  adjacent 
parts  of  the  lungs.  The  fact  that  the  dulness  is  less  marked  at  the 
base  of  the  lung  than  higher  up  helps  to  distinguish  the  condition  from 
hydrothorax. 

The  diagnosis  is  usually  easy,  owing  to  the  presence  of  the  under- 
lying disease.  Fever,  pain,  and  cough  such  as  characterize  croupous 
pneumonia  are  usually  absent. 


CHAPTER  XIX. 

THE  ABDOMEN  IN   GENERAL,  THE   BELLY 

WALLS,  PERITONEUM,  OMENTUM,  AND 

MESENTERY. 

Examination  of  the  Abdomen  in  General. 

Our  methods  are  crude  and  inexact  compared  to  those  applicable 
to  the  chest.  Auscultation,  despite  Cannon's  brilliant  foundation 
studies/  is  of  practically  no  use.  Inspection  is  helpful  in  but  few- 
cases.  Palpation,  our  mainstay,  is  often  rendered  almost  impossible 
by  thickness,  muscular  spasm,  or  ticklishness  of  the  abdominal  walls. 
Percussion  is  of  great  value  in  some  cases,  but  yields  no  useful  results 
in  the  majority. 

Technique. — The  knack  of  abdominal  examination,  and  especially 
that  part  of  it  whereby  the  skilled  diagnostician  gets  his  most  valued 
information,  is  difficult  even  to  demonstrate  and  almost  impossible  to 
describe.  Hence  the  account  of  it  in  this  and  other  books  is  very 
brief  when  compared  with  the  space  allotted  to  the  methods  of  exam- 
ining the  chest.  ^ 

The  table  or  bed  on  which  the  patient  lies  during  most  abdominal 
examinations  (excluding  gynaecological  work)  should  be  at  least  three 
feet  high,  narrow,  and  firm.  Most  beds  are  too  low,  too  wide,  and  too 
soft;  but,  on  the  other  hand,  the  patient  must  not  be  made  uncom- 
fortable by  the  hardness  or  coldness  of  the  surface  on  which  he  lies. 
A  comfortable  pillow  should  be  provided. 

Inspection. — We  need  a  tangential  light,  such  as  accentuates  by 
shadows  every  unevenness  of  the  surface.  If  the  patient  is  examined 
in  the  ordinary  dorsal  decubitus,  the  light  from  any  single  window, 
except  one  overhead,  is  satisfactory.     If  one  inspects  the  abdomen 

^  Summarized  in  his  "Mechanical  Factors  of  Digestion:"  Longman's,  1911. 

^  I  have  heard  a  physician  in  a  leading  American  city  say  that  when  palpation  of  the 
spleen  in  typhoid  fever  was  first  introduced,  there  was  but  one  physician  in  the  city  who 
had  the  knack,  and  that  his  colleagues  were  very  sceptical  about  the  possibility  of  accom- 
pHshing  the  feat  at  all.  I  have  seen  a  similar  uncertainty  regarding  the  palpation  of  the 
normal  but  slightly  displaced  right  kidney. 

338 


THE  ABDOMEN  IN  GENERAL  339 

with  the  patient  upright,  he  should  stand  with  his  side  to  the  light, 
not  facing  it.      By  inspection  we  seek  information  on: 

(a)  The  general  contour  of  the  abdomen. 

(b)  The  surface  of  the  belly  walls,  especially  the  skin  and  the  navel. 

(c)  Respiratory  movements,    their  limitation  or  absence. 

(d)  Peristaltic  movements  (gastric  or  intestinal  in  origin). 

(e)  The   presence    of   local    prominence    or    (rarely)    depression. 
Inspection  of  the  Belly  Wall. — i.  The  surface  of  the  bellywall  is  often 

searched  most  carefully  for  the  rose  spots  of  typhoid  fever,  which  are 
hypersemic,  very  slightly  elevated  spots,  about  the  diameter  of  a  large 
pin  head  (2-4  mm.).  They  disappear  on  pressure.  Pimples  are 
usually  larger,  better  defined  at  the  edges,  and  more  highly  colored, 
contrasting  with  the  very  pale  red  of  most  rose  spots.  They  are  by  no 
means  confined  to  the  belly  and  may  be  found  exclusively  on  the  back. 
Having  been  at  the  outset  somewhat  sceptical  of  their  value  in  diagno- 
sis, I  have  become  thoroughly  convinced  by  greater  experience  and 
more  careful  examination.  Richardson^  has  shown  that  they  often 
contain  bunches  of  typhoid  bacilli.  The  spots  are  present  in  about 
three-fourths  of  all  cases,  and,  while  they  also  may  occur  in  any  dis- 
ease when  the  blood  contains  bacteria  {e.g.,  sepsis),  they  are  common- 
est in  typhoid. 

2.  Distended  and  tortuous  veins  on  the  abdomen  are  seen  in  dis- 
eases obstructing  the  portal  circulation  (rarely  in  cirrhotic  liver)  or 
the  inferior  cava  (see  Fig.  82). 

3.  Striae,  or  linear  markings  on  the  skin  of  the  abdomen,  follow  the 
subsidence  of  any  long-standing  trouble  that  stretches  the  skin — 
pregnancy,  obesity,  tumors,  etc.  They  are  red,  are  angry  when  first 
produced,  but  later  turn  white  {linea  alhicantes) . 

4.  Scars  of  old  wounds  or  operations  may  be  of  great  diagnostic 
value  in  comatose  or  delirious  cases. 

5.  Projection  or  levelling  of  the  normal  depression  at  the  navel  is 
evidence  of  distention,  usually  by  fluid,  within  the  belly. 

Respiratory  movements  of  the  belly  walls  are  limited  or  cease  in 
painful  diseases  within  the  peritoneum  (peritonitis,  lead  colic)  or  when 
the  diaphragm  is  pushed  up  by  a  large  tumor,  ascites,  or  meteorism. 

Peristaltic  waves  creeping  along  beneath  the  belly  walls  are  seen 
with  chronic  stenosis  and  obstruction  at  the  pylorus  or  at  some  point 
in  the  colon  and  occasionally  in  thin  but  healthy  persons. 

Hernice  and  local  and  general  prominences  will  be  discussed  in 
connection  with  abdominal  tumors  (page  343). 

^  M.  W.  Richardson:  Pennsylvania  Medical  Journal,  March  3,  1900. 


340  PHYSICAL  DIAGNOSIS 

Palpation.^ — With  the  patient  on  the  back  upon  a  suitable  bed 
or  table, 2  the  head  on  a  comfortable  pillow,  and  the  abdomen  exposed, 
run  the  palm  of  the  hand  (warm)  lightly  over  the  whole  surface,  to 
accustom  the  muscles  to  its  presence.  Then  try  whether  better 
relaxation  of  the  belly  walls  is  obtained  when  the  patient's  knees  are 
drawn  up.  Some  patients  relax  better  in  this  position;  others  when 
the  legs  are  extended. 

If  the  muscles  of  the  abdomen  remain  contracted  and  stiff  even 
when  the  patient  is  comfortable  and  has  become  accustomed  to  the 
presence  of  the  physician's  hand,  we  may  try  to  induce  relaxation: 

(a)    By  getting  the  patient  to  take  a  series  of  deep  breaths. 

(6)    By  diverting  his  attention  through  conversation  or  otherwise. 

If  these  means  fail  and  it  is  important  that  we  should  thoroughly 
investigate  the  abdomen,  we  have  left  two  further  ways  of  producing 
relaxation,  viz. : 

(c)  By  putting  the  patient  into  a  warm  bath. 

(d)  By  anaesthesia  (ether  or  chloroform) . 

The  movements  of  the  physician's  hand  should  never  be  sudden  or 
rough.  He  should  avoid  digging  into  the  skin  with  his  nails  or  pressing 
strongly  on  a  small  spot  with  the  finger-tips.  If  any  spot  be  suspected 
to  be  tender,  that  should  be  palpated  last,  after  going  over  the  rest  of 
the  abdomen.  If  it  is  necessary  to  make  deep  pressure  at  any  point, 
it  is  best  to  lay  the  fingers  of  the  left  hand  loosely  over  the  spot  and 
then  exert  pressure  upon  them  with  the  fingers  of  the  right  hand. 
The  passive  hand  is  more  sensitive.  To  reach  a  deep  spot,  put  the 
hands  in  this  position  over  it,  ask  the  patient  to  take  a  long  breath, 
and,  as  the  belly  falls  in  expiration,  follow  it  down  with  the  hands. 
Then  hold  what  you  have  gained,  and  with  the  next  full  expiration 
you  may  be  able  to  get  in  still  deeper,  until  after  a  series  of  deep 
breaths  the  desired  spot  is  reached.  Naturally  this  cannot  be  done 
if  there  is  much  tenderness,  but  pure  nervous  spasm  may  sometimes 
be  overcome  in  this  way. 

To  make  use  of  the  relaxation  secured  by  a  hot  bath,  we  need  an 
unusually  long  tub,  so  that  the  patient  can  lie  almost  flat  when  his 
knees  are  slightly  drawn  up.     If  he  is  doubled  up  with  his  knees  and 

'  Special  methods  of  palpating  a  diseased  kidney,  spleen,  or  liver  are  described  in  the 
sections  on  those  organs. 

^  It  is  essential  that  the  physician  as  well  as  the  patient  should  be  comfortable  during  an 
abdominal  examination,  else  his  attention  is  not  wholly  on  his  work.  Hence  the  impor- 
tance of  a  high,  narrow  bed,  or  table,  so  that  the  physician  need  not  stretch  or  stoop  to 
reach  the  patient. 


THE  ABDOMEN  IN  GENERAL  341 

head  in  close  proximity,  nothing  can  be  accomplished.  The  patient 
gets  into  the  tub  with  the  water  comfortably  warm,  and  its  tempera- 
ture is  then  raised  to  between  i  io°  and  120°  F.  by  pouring  in  very  hot 
water.  The  greatest  relaxation  is  usually  attained  after  about  ten 
minutes'  immersion.  When  women  are  examined  the  water  can  be 
rendered  opaque  by  adding  milk  or  soap  suds. 

This  method  is  far  less  inconvenient  than  etherization,  and  is 
especially  valuable  when  the  recti  are  well  developed  and  form  rounded, 
tumor  hke  masses  as  soon  as  ordinary  palpation  is  attempted.  If  we 
suspect  that  a  tumor-like  mass  may  be  one  of  the  bellies  of  the  rectus, 
it  is  well  to  grasp  the  mass  with  the  hand  and  then  ask  the  patient  to 
raise  his  head.     The  mass  will  harden  suddenly  if  it  is  the  rectus. 

What  can  be  Felt  Beneath  the  Normal  Abdominal  Walls. 

No  part  of  the  normal  intestine,  including  the  appendix,  can,  in 
my  opinion,  be  felt  through  the  abdominal  walls.  The  same  is  true  of 
the  stomach,  spleen,  left  kidney,  pancreas,^  bladder,  and  pelvic  organs. 
All  that  we  can  make  out  in  most  normal  cases  is : 

1.  The  abdominal  aorta. 

2.  The  spinal  column,  near  and  above  the  umbilicus. 

3.  Part  of  the  liver  (occasionally,  if  the  costal  angle  is  sharp  and  the 
belly  walls  are  thin  and  lax) . 

4.  The  tip  of  the  right  kidney  (in  many  young  persons) . 

5.  Gurgling  and  splashing  in  the  stomach  or  colon. 

6.  The  ilio  psoas  muscle  and  sometimes  the  beginning  of  the  iliac 
arteries  in  thin  people. 

The  aorta  is  too  deep  to  be  felt  at  all  in  some  persons,  but,  on  the 
other  hand,  it  is  astonishing  how  close  under  the  belly  wall  it  is  in 
others,  i.e.,  in  those  whose  dorsal  spine  projects  sharply  forward.  In 
such  persons  the  aorta  may  be  almost  taken  in  the  hand,  and  its  course, 
calibre,  and  motions  are  so  startlingly  evident  that  it  is  often  mis- 
takenly supposed  to  be  the  seat  of  an  aneurism  (see  above,  page  263), 
especially  as  a  systolic  murmur  and  thrill  can  be  appreciated  over  it 
if  a  little  pressure  is  exerted,  so  as  to  produce  an  artificial  stenosis. 

Behind  and  beside  the  aorta  we  can  sometimes  feel  the  bodies  of 
the  vertebrae,  and  on  them  trace  the  division  of  the  aorta  into  the  com- 
mon iliacs. 

The  liver  cannot  be  felt  at  all  in  the  great  majority  of  normal  per- 

^  Leube  believes  that  in  very  thin  subjects  the  head  of  the  pancreas  may  occasionally  be 
felt. 


342 


PHYSICAL  DIAGNOSIS 


sons,  but  occasionally  the  costal  angle  is  so  sharp  that  a  small  portion 
of  the  organ  is  palpable  in  the  epigastric  region. 

Bimanually  (see  below,  page  390)  the  tip  of  the  normal  right  kid- 
ney may  often  be  caught  between  the  hands  at  the  end  of  a  long  inspira- 
tion, especially  in  young,  thin  people  with  lax  belly  walls. 

If  the  stomach  or  colon  contains  fluids,  the  palpating  hand  often 
elicits  sounds  corresponding  to  the  movement  of  these  fluids.  Their 
only  importance  in  diagnosis  will  be  mentioned  on  page  35 1 . 

Very  deceptive  often  are  muscular  bundles  in  the  external  oblique, 
which  seem  distinguishable  as  sausage-shaped  tumors,  and  doubtless 
give  rise  to  some  of  the  legends  about  feeling  the  normal  appendix. 

Palpable  Lesion  of  the  Belly  Walls. 

The  occurrence  of  lesions,  to  be  recognized  mainly  by  inspection 
and  percussion,  has  been  discussed  (page  338).  Besides  these  we 
search  for: 

I.  HernicB,  epigastric  or  umbilical  (see  Fig.  204).  The  diagnosis 
rests  on  the  presence  of  an  impulse  on  coughing,  with  or  without  a 
reducible  tumor.     Omental  herniae  do  not  bulge  with  cough. 


Fig.  204. — Epigastric  Hernia. 


2.  Separation  of  the  Recti. — When  the  patient,  lying  on  the  back, 
lifts  his  head  and  shoulders,  a  longitudinal  wedge  bulges  out  along  the 
median  line  of  the  belly  from  the  gastric  to  the  suprapubic  region. 

3.  Abscess  of  the  abdominal  walls  usually  represents  a  stitch  abscess 
or  the  external  vent  of  pus  burrowing  from  the  appendix,  the  pelvis, 
or  the  prevesical  space.  But  in  about  one- third  of  the  cases  no  such 
cause  can  be  found.  An  infected  hsematoma  due  to  trauma  or  without 
known  cause  explains  some  cases,  and  occasionally  tuberculosis  or 


THE  ABDOMEN  IN  GENERAL  343 

actinomycosis  occurs.     The  latter  conditions  are  recognized  by  the 
microscopic  examination  of  the  pus  and  of  the  abscess  wall. 

4.  Sarcoma  of  the  belly  wall  is  rather  rare,  and  can  be  recognized 
with  certainty  only  by  microscopic  examination;  without  this  I  have 
known  it  to  be  confused  with  lipoma  and  with  tuberculosis. 

5.  Thickening  or  inflammation  at  the  navel  occurs  in  some  cases  of 
cancerous  or  tuberculous  peritonitis.  The  diagnosis  rests  on  the 
further  evidence  of  cancer  or  tuberculosis  within  the  peritoneal  cavity 
and  on  the  microscopic  examination  of  a  piece  excised  for  the  purpose. 

Palpation  of  the  Spleen  (see  page  386). 
Palpation  of  the  Liver  (see  page  362). 
Palpation  of  the  Kidney  (see  page  390). 

Study  of  Abdominal  Tumors. 

One  should  notice :  Size,  contour,  consistency,  mobility  with  pressure 
and  with  respiration,  tenderness,  pulsation,  peritoneal  crepitus,  adherence 
to  the  skin  or  to  the  abdominal  wall,  relationship- to  any  abdominal  organ 
(also  dulness  or  resonance  on  percussion,  see  below,  page  345). 

Most  of  these  points  need  no  comment.  To  ascertain  whether  the 
tumor  involves  the  skin,  one  lifts  up  a  fold  of  skin  crossing  the  mass. 
If  the  skin  dimples  markedly  over  the  tumor,  i.e.,  fails  to  rise  at  that 
point  while  on  all  sides  of  the  mass  it  can  easily  be  picked  up,  the  skin 
is  adherent.  Tumors  in  the  abdominal  wall  can  usually  be  gathered 
up  along  with  the  latter  when  we  grasp  a  large  fold  with  both  hands. 

To  determine  the  relationship  of  a  tumor  with  the  liver  or  spleen  we 
note: 

(a)  Whether  a  groove  or  interval  can  be  made  out,  by  palpation 
or  percussion,  between  the  mass  and  either  of  those  organs. 

(&)   Whether  its  respiratory  mobility  is  as  great  as  theirs. 

(c)  Whether  there  are  other  facts  in  the  case  suggestive  of  hepatic 
or  splenic  disease  (jaundice,  ascites,  leuksemic  blood). 

(d)  The  effect  of  inflation  of  the  colon  (see  below) .  Tumors  con- 
nected with  the  spleen  are  forced  forward  and  do  not  become  resonant 
when  the  colon  is  inflated. 

To  determine  the  degree  of  respiratory  mobility,  hold  the  fingers  of  one 
hand  in  contact  with  the  lower  edge  of  the  mass  and  allow  them  to 
descend  with  it  while  the  patient  takes  a  full  breath.  To  make  sure 
that  an  actual  descent  occurs,  one  must  sight  the  mass  (and  the  hand) 
against  some  motionless  object  in  the  room  beyond,  else  one  may  be 
deceived  by  the  movement  of  the  abdominal  walls  over  the  tumor, 


344 


PHYSICAL  DIAGNOSIS 


while  the  tumor  itself  remains  motionless  or  nearly  so.  Tumors  con- 
nected with  the  stomach,  omentum,  liver  or  spleen  move  about  two 
inches  with  a  forced  inspiration.  Kidney  tumors  move  less,  seldom 
as  much  as  an  inch.  Pancreatic  and  retroperitoneal  tumors  have 
scarcely  any  mobility.  Those  connected  with  the  intestine  vary  con- 
siderably in  respiratory  mobility,  according  to  the  presence  and  degree 
of  adherence  to  other  parts,  but  their  excursion  is  rarely  an  inch. 

Peritoneal  crepitus  is  a  grating,  rubbing  sensation  experienced  on 
light  palpation,  and  due — supposedly — to  the  presence  of  a  plastic, 
peritoneal  exudate  similar  to  that  which  produces  the  friction  sounds 


Fig.  205. — Diastasis  recti. 


in  pericarditis.  Over  an  enlarged  spleen  {e.g.,  in  leukaemia)  peritoneal 
crepitus  may  be  due  to  local  perisplenitis,  and  in  perigastritis,  peri- 
hepatitis, and  perienteritis  similar  crepitus  occurs. 

Dipping  refers  to  a  sudden  displacement  of  the  abdominal  wall  and 
whatever  lies  close  beneath  it,  by  a  swift  poke  of  the  finger  tips,  which 
may  succeed  thereby  in  touching  a  solid  organ  or  tumor  which  gentle, 
gradual  palpation  misses.  Thus  one  may  reach  and  mark  out  an 
enlarged  liver  through  a  layer  of  ascites  which  would  prevent  ordinary 
palpation. 


THE  ABDOMEN  IN  GENERAL  345 

Percussion. — Abdominal  percussion  is  less  valuable  than  tho- 
racic. A  lighter  blow  is  used,  and  the  distinction  between  dulness  and 
tympany  is  easy.  It  is  of  value  chiefly  to  determine  the  presence  of 
fluid  free  in  the  peritoneal  cavity,  and  to  ascertain  whether  a  tumor  is 
due  to  or  covered  by  gaseous  distention. 

(o)  Free  fluid  (ascites,  peritonitis,  hsemoperitoneum,  ruptured 
cyst)  gravitates  to  the  flanks  and  suprapublic  region,  while  the  intes- 
tines float  up  and  occupy  the  epigastric  and  umbilical  space.  Hence 
there  is  dulness  in  the  flanks  and  over  the  pubes,  with  resonance  in  the 
epigastric  and  umbilical  regions.  But  the  crucial  and  ever-necessary 
test  is  the  shifting  of  this  area  of  dulness  when  the  patient  turns  on  his 
side;  then  the  uppermost  flank  should  become  resonant  and  the  lower 
half  of  the  belly — including  part  of  the  umbilical  region — dull.  With- 
out this  test  the  mere  marking  out  of  dull  areas  in  the  flanks  is  not 
conclusive  evidence  of  free  fluid  there.  Occasionally  one  is  deceived 
by  the  shifting  of  a  distended  colon  or  a  mass  of  small  intestines  con- 
taining fluid.  Still  less  reliable  is  the  "fluctuation  wave,"  which  can 
be  transmitted  as  an  impulse  palpable  to  the  hand  laid  flat  on  one 
flank,  by  sharply  snapping  the  other  flank.  Similar  impulses  can  be 
transmitted  through  the  fat  of  the  belly  wall,  despite  all  efforts  to 
check  them  by  pressure  upon  the  latter. 

(6)  Percussion  is  our  final  test  in  the  diagnostic  procedure  that 
begins  with  inflation  of  the  colon.  Air  is  forced  into  the  rectum  with 
an  ordinary  Davidson  syringe,  and,  as  the  colon  becomes  prominent 
and  hyperresonant,  we  note  whether  its  tympany  covers  up  the  tumor- 
mass  under  investigation,  or  whether  the  mass  lies  anterior  to  and 
remains  dull  over  the  inflated  colon.  Kidney  tumors  lie  behind  the 
inflated  colon;  splenic  tumors  remain  dull  in  front  of  it. 

Auscultatory  percussion,  for  identification  or  demarkation  of  ab- 
dominal tumors  and  organs,  has  never  been  successful  in  my  hands 
nor  in  those  of  most  of  the  observers  in  whose  results  I  have  confidence. 
Hence  I  omit  further  description  of  it. 

Percussion  of  the  stomach  and  spleen  (see  below,  pages  354  and  385) . 

Percussion  of  Traube's  semilunar  tympanitic  space  (the  small  area 
bounded  on  the  right  by  the  splenic  and  on  the  left  by  the  hepatic 
dulness,  above  by  the  free  edge  of  the  left  lung,  and  below  by  the  lower 
edge  of  the  ribs)  is,  in  my  experience,  of  very  little  value  in  diagnosis. 
This  tympanitic  area  is  obliterated  in  many  pleuritic  effusions  (not 
in  all),  but  many  other  causes  (full  stomach  or  gut,  obese  omentum) 
may  produce  similar  dulness. 

Before  describing  the  signs  of  the  different  diseases  to  which  the 


346  PHYSICAL  DIAGNOSIS 

abdominal  organs  are  subject  it  seems  to  me  best  to  introduce  here  a 
list  of  the  commoner  abdominal  tumors  found  in  the  study  of  4876  such 
tumors  at  the  Massachusetts  General  Hospital. 

Relative  Frequency  of  Abdominal  Tumors. 

1.  Congested  liver , 1288 

2.  Uterine  fibromyoma 766 

3 .  Hernia 488 

4.  Ovarian  cyst 382 

5.  Gastric  cancer 285 

6.  Displaced  kidney 227 

7 .  Cirrhotic  liver 153 

8.  Cancer  of  liver 151 

g.  Cancer  of  colon 90 

10.  Abscess  of  abdominal  wall 79^ 

11.  Splenic  tumor  in  cirrhosis  of  the  liver 60 

12.  Leukcemic  spleen 58 

13.  Malignant  tumor  of  the  ovary 43 

14.  Tuberculous  kidney 41 

15.  Tumor  as  part  of  tuberculous  peritonitis 33 

16.  Cancer  of  the  pancreas 32  ^ 

17.  Neoplasm  of  the  kidney 27 

18.  Sarcoma  of  abdominal  wall 27 

19.  Enlarged  spleen  of  unknown  cause 26 

20.  Omental  cancer 18 

21.  Intussusception 17 

Diseases  of  the  Peritoneum. 

1.  Peritonitis — local  or  general. 

2.  Ascites. 

3.  Cancer  and  tuberculosis. 

/.   Peritonitis. 

I.  Local  peritonitis  gives  evidence  of  its  presence  by  (a)  pain, 
(&)  tenderness,  (c)  muscular  spasm,  {d)  tumor,  and  (e)  constitutional 
manifestations. 

The  pain  may  be  at  first  diffuse,  later  localizing  itself  at  the  site  of 
the  lesion ;  or  it  may  be  felt  first  where  the  peritonitis  begins  and  spread 
with  the  lesion  if  the  general  peritoneal  cavity  becomes  involved.  The 
character  and  intensity  of  the  pain  vary  greatly. 

^  Some  of  these  were  so  small  as  hardly  to  deserve  classification  as  tumors. 
^  Rarely  produces  a  palpable  tumor  but  is  here  mentioned  for  convenience. 


THE  ABDOMEN  IN  GENERAL  347 

Tenderness  is  the  important  sign  in  diagnosis,  and  helps  us  to 
exclude  the  various  colics  and  other  causes  of  pain  which  are  often 
relieved  by  pressure. 

Local  muscular  spasm  of  the  belly  muscles  to  guard  the  tender  le- 
sion beneath  is  of  great  value  in  pointing  our  attention  to  the  spot 
affected,  though  the  muscles  may  be  so  rigid  as  to  prevent  palpation 
through  them.  [Psoas  spasm  is  described  in  the  section  on  appendi- 
citis, see  page  376.] 

The  tumor  is  apt  to  consist  of  intestine  or  other  organs  matted 
together  by  adhesions  about  the  site  of  the  process. 

The  constitutional  manifestations  are  those  of  infection,  viz., 
fever,  leucocytosis,  anorexia,  constipation,  often  albuminuria  and 
albumosuria. 

The  commonest  causes  of  local  peritonitis  are: 

1.  Appendicitis. 

2.  Pus  tube. 

3.  Gall-bladder  inflammation. 

Less  common  is  cancer  or  ulcer  of  the  stomach  or  intestine. 

2.  General  Peritonitis. — The  belly  may  be  generally  swollen  and 
tympanitic  or  retracted  and  hard.  General  tenderness  is  the  most  im- 
portant sign.  In  advanced  cases  free  fluid  in  the  flanks  may  be  demon- 
strated, as  explained  on  page  345.  Faeces  and  even  gas  cease  to  move, 
as  the  intestines  are  paralyzed.  Vomiting  is  the  rule,  and  soon  be- 
comes very  foul  (stercoraceous) .  There  is  fever,  with  a  rapid  and 
very  weak  pulse.  The  mind  is  clear,  alert.  The  facial  expression  is 
not  peculiar  and  may  be  normal.  If  there  is  persistent  vomiting  the 
facies  of  that  condition  appears,  viz.,  a  drawn,  pinched,  anxious  look, 
with  dark  circles  under  the  eyes.  The  nausea  and  the  rapid  loss  of 
fluid  by  vomiting  account  for  these  appearances. 

The  leucocyte  count  is  generally  elevated,  but  in  the  most  viru- 
lent cases  remains  normal  or  subnormal. 

//.  Ascites. 

The  commonest  causes  are: 

(i)   Dropsy,  from  cardiac,  pericardial,  or  renal  disease. 

(2)  Portal  stasis,  usually  from  cirrhosis  of  the  liver. 

(3)  Tuberculous  peritonitis. 

(4)  Cancer  of  the  peritoneum. 

(5)  Solid  ovarian  tumors. 

The  methods  of  diagnosis  of  ascites  have  been  explained  above. 


348 


PHYSICAL  DIAGNOSIS 


The  diagnosis  of  its  cause  depends  on  the  history,  the  results  of  punc- 
ture, and  the  general  physical  examination.  The  contour  of  the  belly 
is  often  that  pictured  in  Fig.  206. 


///.   Cancer  and  Tuberculosis  of  the  Peritoneum. 

In  connection  with  cancer  or  tuberculosis  of  some  abdominal  or 
pelvic  organ,  the  disease  may  become  spread  throughout  the  perito- 
neum with  deposits  in  the  omentum  and  mesentery.     The  signs  are: 

I.  Tumor  masses  scattered  here  and  there, 
sometimes  at  the  navel.  2.  Ascites.  3. 
Emaciation  and  anaemia. 

The  diagnosis  of  cancer  depends  on  the 
recognition  of  multiple,  hard,  nodular 
tumors  in  the  abdomen  of  a  patient  known 
to  have  cancer  of  some  abdominal  organ. 

Somewhat  similar  masses,  usually  due 
to  loops  of  intestine  matted  together  by 
adhesions,  may  be  felt  in  tuberculous  peri- 
tonitis, but  here  they  are  larger,  fewer,  and 
not  so  hard.  Cancer  appears  in  late  life, 
tuberculous  peritonitis  usually  in  early 
life.  The  emaciation  and  ansemia  are  less 
marked  in  tuberculosis,  and  fever  is  more 
marked.  The  history  or  present  evidence 
of  tuberculosis  elsewhere — lung,  pleura, 
glands,  pelvis,  testis — favors  the  diagnosis 

Cytodiagnosis  and  the  tuberculin  test 


Fig.  206. — Characteristic  Shape 
of  Belly  in  Ascites. 


of   tuberculous   peritonitis, 
may  be  of  value  in  diagnosis. 

Subphrenic  Abscess. — There  are  two  common  types — the  one  near 
the  liver,  the  other  near  the  spleen. 

(a)  The  perihepatic  type  is  recognized,  as  a  rule,  chiefly  by  its 
etiology  (perforated  gastric  ulcer  appendix-abscess),  by  the  constitu- 
tional signs  of  concealed  pus  (fever,  chills,  leucocytosis) ,  and  to  a  less 
extent  by  physical  signs,  none  of  which,  however,  serves  to  distinguish 
perihepatic  from  intrahepatic  pus.  Pain  in  the  hepatic  region,  promi- 
nence of  the  right  lower  ribs  or  right  hypochondrium,  increased  area 
of  percussion  dulness  over  the  lower  ribs  in  front  and  behind  (whence 
empyema  or  pneumonia  is  often  suspected),  and  the  results  of  :r-ray 
examination  are  the  data  from  which  we  must  reason. 

(b)  The  perisplenic  type  of  abscess  follows  a  general  peritonitis. 


THE  ABDOMEN  IN  GENERAL  349 

which  has  been  treated  by  drainage  and  recumbency.  The  pus 
becomes  pocketed  near  the  spleen  instead  of  gravitating  toward  the 
pelvis  as  it  does  if  the  patient's  trunk  is  kept  upright. 

Pain,  sometimes  tenderness,  the  history  of  the  case  and  the  consti- 
tutional evidence  of  concealed  pus  are  the  facts  on  which  a  conjecture 
may  be  hazarded. 

The  Mesentery. 

1 .  Enlarged  glands — tuberculous,  cancerous,  or  as  part  of  Hodgkin's 
disease — can  occasionally  be  felt  in  very  thin  patients.  Their 
recognition  as  glands  would  depend  on  more  obvious  evidence  of 
their  cause  in  other  parts  of  the  body. 

2.  Mesenteric  thrombosis  produces  all  the  signs  of  intestinal  ob- 
struction (see  below,  page  377),  from  which  it  can  rarely  if  ever  be 
distinguished  without  operation  or  autopsy. 


CHAPTER  XX. 

THE  STOMACH,  LIVER,  AND  PANCREAS. 

The  Stomach. 

The  best  methods  of  examining  the  stomach  are : 

1.  Inspection  and  palpation  of  the  epigastrium  and  the  neighbor- 
ing portions  of  the  abdomen. 

2.  Estimation  of  the  size  and  position  of  the  organ  after  distending 
it  with  air  or  water. 

3.  Examination  of  the  stomach  contents:  (a)  fasting;  (&)  after 
a  test  meal. 

4.  Bismuth — rc-ray  examination. 

By  combining  the  results  of  these  four  methods  of  examination 
with  the  results  of  our  general  examination  of  the  body — emaciation, 
anaemia,  etc. — and  with  the  data  obtained  by  a  careful  history,  we 
obtain  all  the  information  about  the  stomach  which  it  is  possible  for 
us  to  make  use  of  at  the  present  time. 

I.  Inspection  and  Palpation  of  the  Epigastrium. 

(a)  Tenderness. — The  normal  stomach  cannot  be  seen  or  felt,  nor 
can  anything  certain  be  learned  in  regard  to  it  by  percussion  or  auscul- 
tation. Tenderness  in  the  epigastrium  is  so  common  that  we  can 
attach  no  significance  to  it  unless  it  is  extreme  and  sharply  localized 
in  a  small  area.  In  a  small  proportion  of  cases  cutaneous  tenderness 
in  the  back  (lower  dorsal  or  upper  lumbar  region)  can  be  elicited  in 
cases  of  peptic  ulcer. 

(b)  A  tumor  in  the  epigastrium  (see  Fig.  207)  is  of  far  greater  impor- 
tance than  any  other  local  evidence.  If  it  occurs  in  an  emaciated  and 
anaemic  person  past  middle  life,  is  hard  and  nodular,  and  does  not 
disappear  after  catharsis,  it  is  almost  invariably  due  to  cancer  of  the 
stomach.  Such  a  tumor  may  also  be  due  to  a  mass  of  adhesions  about 
a  gastric  ulcer.  Tumors  of  the  pancreas  much  less  often  reach  the 
surface  in  this  region;  tumors  of  the  liver  are  generally  larger,  and 
their  connection  with  this  organ  can  generally  be  demonstrated  by 
percussion,  palpation,  and  by  their  greater  respiratory  mobility  when 
compared  with  gastric  cancer. 

3.50 


THE  STOMACH,  LIVER,  AND  PANCREAS 


351 


Epigastric  hernia  usually  shows  an  impulse  on  coughing,  is  soft  and 
doughy  in  feel,  and  presents  none  of  the  other  symptoms  and  signs  of 
gastric  cancer. 

Tubercular  deposits  in  the  omentum  are  almost  always  associated 
with  ascites,  fever,  and  other  evidences  of  tuberculosis  either  in  the 
examination  of  other  organs  or  in  the  history. 

(c)  Visible  gastric  peristalsis  means  stenosis  of  the  pylorus  (cancer, 
cicatrix,    adhesions,    simple    thickening,    or   muscular    spasm).     The 


Fig.  207. — Epigastric  Tumor  in  Gastric  Cancer. 

contraction  wave  passes  from  left  to  right  across  the  epigastrium,  and 
is  seen  by  means  of  the  shadow  cast  by  a  tangential  light  with  the 
patient  in  a  recumbent  position.  If  the  peristalsis  stops  it  can  some- 
times be  reexcited  by  briskly  snapping  the  epigastric  region  with  the 
finger. 

(d)  The  normal  splash  sound  can  usually  be  heard  if  sudden,  quick 
pressure  is  made  in  the  epigastrium  within  three  hours  after  a  meal. 
If  splashing  can  be  elicited  more  than  three  hours  after  a  meal,  and 
especially  if  it  is  present  before  breakfast,  it  is  evidence  of  gastric 
stasis  and  usually  of  dilatation. 

(e)  Hypogastric  bulging  due  to  dilated  stomach  is  occasionally  seen 
in  cases  of  marked  dilatation  when  the  patient  stands  up,  and  is  exam- 
ined in  profile  (see  Fig.  208). 


2.  Estimation  of  the  Size,  Position,  Secretory  and  Motor  Power  of  the 

Stomach. 

Whenever  we  cannot  arrive  at  a  satisfactory  diagnosis  by  means 
of  the  above  methods  of  external  examination  when  taken  in  connec- 
tion with  the  history  and  the  general  condition  of  nutrition,  we  must 


352  PHYSICAL  DIAGNOSIS 

undertake  a  more  direct  investigation  of  the  organ,  which  begins  with 
(a)  the  passage  of  the  stomach  tube.  The  standard  red  rubber  tube 
generally  in  use  in  this  country  comes  in  two  sizes.  Personally  I 
prefer  the  larger,  with  a  lateral  as  well  as  a  terminal  opening  at  the 
lower  end,  although  the  smaller  size  produces  somewhat  less  discom- 
fort. The  patient  should  be  covered  by  a  rubber  sheet  and  the  cloth- 
ing removed  from  his  abdomen.  So  prepared,  he  should  sit  in  a 
straight-backed,  wooden  chair,  with  a  good-sized  foot- tub  between 


Fig.  208. — Outline  of  Abdomen  in  Dilatation  of  the  Stomach. 

his  feet  and  a  towel  in  his  hand  ready  to  wipe  away  the  profuse  secre- 
tions of  the  mouth  and  pharynx.  He  should  then  be  warned  that  the 
process  of  passing  a  tube,  although  entirely  free  from  danger,  is  very 
disagreeable,  both  on  account  of  the  nausea  which  it  produces  and 
because  it  often  seems  to  the  patient  as  if  he  were  choking  and  could 
not  get  his  breath.  This,  in  fact,  is  not  the  case,  and  if  the  patient  will 
persist  in  drawing  long,  deep  breaths  throughout  the  process  of  passing 
a  tube,  the  worst  of  it  is  over  in  twenty  seconds. 

The  tube  is  moistened  with  water  and  pushed  straight  down 
through  the  pharynx  without  any  attempt  to  direct  it,  beyond  keeping 
the  median  line.  There  is  no  danger  of  entering  the  trachea  and  no 
use  in  trying  to  avoid  it.     On  its  way  down  the  tube  is  arrested  now 


THE  STOMACH,  LIVER,  AND  PANCREAS  353 

and  then  by  muscular  spasm  of  the  oesophagus,  but  after  a  few  seconds 
the  spasm  relaxes  and  allows  us  to  push  the  tube  on  until  the  twenty- 
two-inch  mark  reaches  the  teeth.  The  lower  end  of  the  tube  is  then 
in  the  stomach/  and  we  are  ready  to  extract  the  gastric  contents  (in 
case  a  test  meal  has  been  previously  given) ,  to  wash  out  the  organ,  or 
to  distend  it  with  air  or  water.  Since  the  passage  of  the  stomach  tube 
is  the  means  whereby  we  become  sure  of  the  existence  of  such  diseases 
as  cardio-spasm,  diverticulum  of  the  gullet  and  cancerous  stricture  of 
the  gullet,  some  account  of  the  diagnos  is  of  these  diseases  will  be  given 
here. 

Cardiospasm  with  Dilatation  of  the  Esophagus. — Plummer  has 
reported  40  cases  seen  in  the  Mayos'  clinic  within  two  and  a  quarter 
years.  Hence  the  disease  cannot  be  a  rare  one  though  there  are  less 
than  200  more  cases  on  record.  The  patient  complains  that  food 
sticks,  causing  discomfort  at  the  lower  end  of  the  sternum  and  later 
regurgitating  unmixed  with  acid  juice.  The  cases  usually  begin  at  so 
early  an  age  (29  is  the  average)  and  are  usually  chronic  enough  when 
seen  to  exclude  a  cancerous  stricture,  but  as  a  rule  the  first  reliable 
evidence  on  this  point  is  obtained  when  we  find  that: 

1.  A  stomach  tube  will  not  pass  while  a  large  sound  passes  fairly 
easily. 

2.  Great  and  long-continuing  relief  is  obtained  by  dilating  the 
stricture  a  few  times  with  water  pressure  inside  a  silk  covered  rubber 
bag. 

Radiography  of  a  bismuth  meal  and  the  use  of  the  esophagoscope 
are  supplementary  aids  to  diagnosis.  If  there  is  any  difficulty  in 
reaching  the  stomach,  a  silk  thread  six  yards  long  is  swallowed. 
After  the  lower  end  has  passed  into  the  gut  the  upper  end  can  be  pulled 
taut  and  on  it  as  a  guide  a  sound  and  subsequently  a  dilator  can  be 
passed. 

Diverticulum  of  the  Esophagtis. — Most  diverticula  are  so  high  up  in 
the  gullet  that  they  are  easily  recognized  by  radiography  and  sounding. 
The  rarer  diverticula  low  down  in  the  esophagus  can  also  be  recognized 
in  most  cases  by  radiographing  a  bismuth  meal  or  the  silk  thread 
method  above  described.  The  thread  guides  the  sound  past  the 
opening  of  the  diverticulum. 

Cancer  of  the  Esophagus. — The  age  of  the  patient  and  the  duration 
of  symptoms  usually  differentiate  cancer  of  the  gullet  from  cardio- 

^  Unless  there  is  gastric  dilatation  or  gastroptosis ;  then  the  tube  must  be  pushed  in 
several  inches  farther,  the  distance  depending  on  the  position  of  the  lower  gastric  border, 
as  determined  in  previous  examinations. 
23 


54  PHYSICAL  DIAGNOSIS 

Spasm.  In  doubtful  cases  the  fact  that  sounds  even  when  accurately 
guided  do  not  pass  much  more  easily  than  the  soft  rubber  tube  favors 
the  diagnosis  of  cancer. 

(b)  Extracting  the  Gastric  Contents. — One  hour  after  a  test  meal^ 
the  tube  is  passed  and  the  patient  is  then  asked  to  lean  forward,  press 
with  his  hands  upon  his  stomach,  and  strain  down  as  if  he  were  going 
to  have  a  movement  of  the  bowels.  In  most  cases  this  suffices  to  force 
the  gastric  contents  out  through  the  tube  and  into  a  basin,  which  is 
held  ready.  If  the  gastric  contents  cannot  be  extracted  either  in  this 
way  by  having  the  patient  lie  down  or  by  moving  the  tube  in  the 
pharynx  so  as  to  excite  nausea,  we  should  make  sure  first  that  the  eye 
of  the  tube  is  not  plugged.  This  may  be  ascertained  by  disconnecting 
the  funnel  and  blowing  through  the  tube,  which  usually  suffices  to 
discharge  any  obstacle  from  the  eye  of  the  tube.  If  still  the  gastric 
contents  do  not  flow  out,  we  may  use  suction  by  connecting  a  Politzer 
air-bag  with  the  end  of  the  tube  in  place  of  the  funnel. 

For  the  analysis  of  the  contents  so  obtained,  see  below,  page  355. 

(c)  Distending  the  Stomach. — We  may  use  either  air  or  water.  The 
first  is  more  comfortable,  the  second  rather  more  accurate.  To 
distend  the  stomach  with  air,  disconnect  the  funnel  and  attach  a 
Davidson  syringe.  Then  have  the  patient — ^still  with  the  tube  in  his 
stomach — lie  down  upon  a  bed  with  the  abdomen  exposed,  and  pump 
air  rapidly  in  with  the  Davidson  syringe.  The  rapid  entrance  of  air 
causes  a  reflex  closure  of  the  pylorus  and  allows  us  to  distend  the 
stomach.  While  an  assistant  pumps  in  the  air,  we  inspect  and  percuss 
the  epigastric  region,  which  soon  begins  to  bulge  out  and  assume  on 
percussion  a  tympanitic  note  differing  clearly  in  pitch  and  quality 
from  that  obtained  in  other  portions  of  the  abdomen.  Auscultation 
is  also  of  value  for  the  note  produced  by  the  puff  of  air  entering  the 
stomach  is  much  louder,  sharper,  and  more  metallic  when  one's 
stethoscope  is  over  the  stomach  than  when  one  has  moved  the  instru- 
ment beyond  the  gastric  limits.  After  a  certain  amount  of  air  has 
been  pumped  in,  the  lower  border  of  the  stomach  (as  shown  by  percus- 
sion) ceases  to  descend,  and  about  this  time  the  patient  begins  either  to 
complain  of  pain  or  to  belch  up  wind  around  the  tube,  showing  that 
the  organ  is  fully  distended.  We  then  mark  upon  the  abdominal  wall 
the  position  of  the  lower  border  of  the  stomach,  and  if  possible  of  the 
upper,  which  can  usually  be  obtained  by  percussion. 

Position  of  the  Normal  Stomach. — The  lower  border  of  the  normal 
stomach  after  air  distention  rarely  descends  below  the  level  of  the 
^  A  slice  of  bread  and  a  glass  and  a  half  of  water  is  a  good  test  meal. 


« 


THE  STOMACH,  LIVER,  AND  PANCREAS  355 

umbilicus;  hence  any  stomach  whose  lower  border  descends  lower  than 
this  should  be  considered  dilated,  provided  that  the  upper  border  is 
approximately  in  the  normal  situation.  If  the  upper  border  is 
lowered  as  much  as  the  fundus,  we  are  probably  dealing  with  a  case 
of  gasiro ptosis  or  dropping  of  the  whole  organ. 

To  distend  the  stomach  with  water,  we  simply  pour  it  in  through 
the  funnel  until  the  patient  complains  of  decided,  discomfort  and  ful- 
ness. We  then  note  the  amount  poured  in,  let  the  funnel  empty  into 
a  large  foot-tub  on  the  floor,  allow  the  water  to  siphon  out,  and 
measure  the  amount  so  obtained.  The  normal  stomach  will  hold 
about  1,500  c.c.  (or  three  pints).  Anything  over  this  amount  is 
pathological.  A  difficulty  of  the  method  of  distention  by  water  is  that 
it  is  sometimes  impossible  to  get  out  of  the  stomach  all  of  the  water 
that  we  have  put  into  it,  whereas  with  distention  with  air  there  is  no 
difficulty  in  forcing  out  the  air  through  and  around  the  tube  by  pres- 
sure on  the  epigastrium. 

(d)  Washing  the  Stomach  (Lavage). — Though  not  of  much  use  in 
diagnosis,  this  procedure  may  be  briefly  mentioned  here.  After  intro- 
ducing the  tube  as  above  described,  about  a  pint  of  water  is  poured  in 
through  the  funnel,  and,  just  before  the  water  disappears  in  the  vortex 
of  the  funnel,  the  latter  is  rapidly  lowered  so  as  to  empty  by  siphonage 
into  a  vessel  on  the  floor.  This  process  is  repeated  until  food  and 
mucus  cease  to  come  out  and  the  water  runs  clear. 

To  remove  the  tube  at  the  end  of  any  of  the  procedures  just  de- 
scribed, we  have  only  to  pinch  it  tightly  just  outside  of  the  patient's 
teeth  and  pull  it  rapidly  out. 

3.  Examination  of  Gastric  Contents. 

1 .  The  contents  of  the  fasting  stomach  are  best  obtained  by  passing 
the  tube  before  breakfast,  and  should  consist  of  no  more  than  a  few 
cubic  centimetres  of  clear  fluid  containing  free  hydrochloric  acid.  If 
any  food  is  present,  gastric  stasis  is  proven.  If  more  than  50  c.c.  of 
fluid  without  food  are  present,  hypersecretion  is  indicated. 

2.  Gastric  Contents  after  a  Test  Meal. — -The  best  test  meal  is  that 
of  Ewald,  and  consists  of  a  slice  of  bread  (or  its  equivalent  in  crackers 
or  cereal)  with  a  glass  and  a  half  of  water.  After  this  meal  not  more 
than  100  c.c.  should  be  found  in  the  stomach  at  the  end  of  an  hour. 
Occasionally  the  stomach  has  emptied  itself  even  within  the  hour,  and 
we  have  then  to  reduce  the  period. 

After  extracting  the  gastric  contents  as  above  described  and  noting 


356  PHYSICAL  DIAGNOSIS 

the  quantity,  we  should  investigate  also  their  color,  odor,  and  general 
appearance,  (a)  Small  streaks  of  blood  are  of  no  consequence. 
Considerable  quantities  of  blood  (fresh)  suggest  ulcer.  Small  quanti- 
ties of  dark-brown  substance  resembling  blood  should  be  investigated 
by  the  guaiac  test.     If  this  is  positive,  gastric  cancer  is  suggested. 

The  guaiac  test  is  best  performed  as  follows:  Chip  off  the  oxidized 
outer  shell  of  a  lump  of  gum  guaiac  and  prepare  a  fresh  tincture  by 
shaking  a  few  chips  of  the  inner  non-oxidized  guaiac  with  a  few  cubic 
centimetres  of  alcohol.  Add  about  lo  drops  of  this  tincture  and  2  c.c. 
of  hydrogen  peroxide  to  an  ethereal  solution  of  the  gastric  contents 
prepared  by  extracting  10  c.c.  of  gastric  contents  with  2  c.c.  of  glacial 
acetic  acid  and  15  c.c.  of  ether  (shake  5  minutes).  On  adding  the 
guaiac  to  the  ethereal  solution  of  gastric  contents  a  blue  color  indicates 
the  presence  of  blood. 

(&)  For  acetic  and  butyric  acids  we  test  merely  by  our  sense  of 
smell.  Whenever  stasis  or  fermentation  has  occurred,  we  are  apt  to 
get  a  characteristic  odor  of  these  acids  mingled  with  that  of  yeast. 

(c)  The  general  appearance  of  the  contents  tells  us  little  that  is 
important.  In  cases  of  marked  dilatation  they  often  separate  into 
three  layers — the  upper  frothy,  the  middle  a  thin,  turbid  liquid,  and 
the  lower  a  fiocculent  sediment  of  partially  digested  food. 

Mucus  is  not  of  any  considerable  clinical  significance  unless  it  is  so 
abundant  that  the  whole  stomach  contents  will  slide  in  one  lump  from 
one  beaker  to  another. 

When  absolutely  no  digestion  has  taken  place,  as  in  the  rare  cases 
of  achylia  gastrica,  the  contents  consist  simply  of  unaltered  bread  and 
water. 

Chemical  Tests  of  Gastric  Contents. 

1 .  Dip  a  piece  of  blue  litmus  in  the  contents ;  if  no  reddening  occurs, 
no  further  tests  need  be  made. 

2.  If  the  contents  are  acid  to  litmus,  test  with  Gunzhurg's  reagent 
(phloroglucin,  2  gm.;  vanilHn,  i  gm.;  alcohol,  30  gm.),  by  mixing  two 
drops  of  it  with  an  equal  amount  of  gastric  contents  (unfiltered)  upon 
a  white  porcelain  plate  or  dish,  and  evaporating  slowly  over  a  flame.  ^ 
If  free  HCl  is  present,  a  bright  rose  pink  appears.  In  the  absence  of 
free  HCl,  the  color  is  a  dirty  yellowish-brown. 

If  this  test  is  positive,  we  need  make  no  further  tests  except  the 
following : 

1  The  same  test  may  be  performed  on  a  glass  slide  which  is  subsequently  put  upon  a 
piece  of  white  paper  to  bring  out  the  color. 


THE  STOMACH,  LIVER,  AND  PANCREAS  357 

Quantitative  Estimation  of  free  HCl  and  of  Total  Acidity. 

To  lo  c.c.  of  unfiltered  gastric  contents  add  four  drops  (about)  of 
Topfer's  reagent  (dimethyl-amido-azo-benzol :  0.5  per  cent  alcoholic 
solution)  in  a  beaker;  a  carmine-red  color  results.  Fill  a  graduated 
burette  with  decinormal  NaOH  solution,  and  let  it  run  out  into  the 
beaker,  a  few  drops  at  a  time,  until  the  carmine-red  color  disappears. 
While  titrating  stir  the  mixture  constantly  with  a  glass  rod.  Note  the 
number  of  cubic  centimetres  of  NaOH  that  have  run  out."^ 

To  estimate  the  quantity  of  free  HCl,  multiply  the  number  of  cubic 
centimetres  of  NaOH  used  in  the  titration  by  0.0365;  the  result  is  the 
percentage  of  free  HCl.  Normal  free  HCl  varies  from  0.07  to  0.2 
per  cent,  or  from  2  to  6  c.c.  of  decinormal  NaOH  for  10  c.c.  of  gastric 
contents. 

The  estimation  of  combined  HCl  and  of  the  acid  salts  is  seldom  of 
importance. 

Total  acidity  is  determined  by  adding  to  the  same  beaker  of  contents 
in  which  the  free  HCl  has  just  been  neutralized  two  or  three  drops  of 
a  one-per-cent  solution  (alcoholic)  of  phenolphthalein,  and  continuing 
the  titration  with  the  NaOH  solution  (and  constant  stirring)  until  a 
permanent  red  color  appears.  By  multiplying  the  number  of  cubic 
centimetres  of  NaOH  used  from  the  beginning  of  the  first  titration  up 
to  the  point  when  the  red  color  reappears  by  0.0365,  we  obtain  a  figure 
I  presenting  the  percentage  of  total  acidity.  The  normal  range  of 
total  acidity  is  from  0.15  to  0.3  per  cent,  and  we  usually  find  that  we 
have  used  from  4  to  8  c.c.  of  the  NaOH  solution  in  the  process  of 
neutralizing  10  c.c.  of  gastric  contents. 

Lactic  acid  is  to  be  tested  for  only  when  HCl  is  absent.  The  test 
must  be  made  at  once,  since  lactic  acid  soon  develops  in  stomach 
contents  which  are  kept  in  a  warm  place.  To  perform  the  test,  we 
dilute  a  solution  of  FeCl  (strong  aqueous)  with  water  until  a  faint 
yellow  color  barely  remains.  Then  fill  the  concavities  of  two  test 
tubes  with  this  solution,  using  one  for  comparison.  If,  on  adding  a 
few  drops  of  stomach  contents  to  the  other,  a  considerable  intensifica- 
tion of  the  yellow  color  occurs,  lactic  acid  is  almost  certainly  present. 
A  negative  test  rules  out  lactic  acid. 

^  An  ordinary  medicine-dropper  may  be  substituted  for  the  burette  if  we  get  an  apothe- 
cary to  mark  with  a  file  upon  it  the  point  to  which  a  (previously  measured)  cubic  centimetre 
of  water  rises  when  sucked  into  the  dropper.  The  half-centimetre  point  can  be  similarly 
marked.  Decinormal  NaOH  solution  is  then  sucked  into  the  dropper  and  expelled,  one- 
half  centimetre  at  a  time,  into  the  beaker  containing  the  Topfer's  reagent  and  gastric 
contents. 


358 


PHYSICAL  DIAGNOSIS 


The  sediment  need  not  be  examined.  It  is  true  that  sarcinse  and 
various  bacteria  (Boas-Oppler  bacillus  and  others)  are  often  found  in 
cases  of  gastric  stasis,  but  they  add  little  if  anything  to  the  other  evi- 
dence of  stasis  more  easily  obtained — i.e.,  the  symptoms  mentioned  on 
page  361,  the  presence  of  splashing  more  than  four  hours  after  a  meal, 
the  evidence  of  dilatation  or  gastroptosis  as  given  above,  and  the  find- 
ing of 'organic  acids. 

4.  Bismuth  X-ray  Exam-ination  of  the  Stom,ach. 

From  two  to  four  ounces  of  bismuth  subcarbonate  suspended  in 
milk  or  mucilage  of  acacia  are  taken  on  an  empty  stomach  (say  at 
5  A.  M.).     Six  hours  later  the  patient  is  radiographed  in  the  upright 


Fig.  209a. — Radiograph  of  Normal  Stomach  After  Bismuth.  B.  First  portion  of 
Duodenal.  P.  Pyloric  Ring.  C,  C.  Normal  Contraction  Rings.  G,  G,  G,  G.  Bismuth 
in  Gut. 


position.  There  should  be  then  no  bismuth  residue  in  the  stomach. 
The  presence  of  any  such  residue  is  strong  evidence  that  stasis  and, 
therefore,  some  of  the  causes  of  stasis, — gastric  cancer,  peptic  ulcer 
(gastric  or  duodenal),  adhesions  or  ptosis,  are  present. 

Immediately  after  this  test  for  stasis,  a  second  bismuth  meal  is 
given  and  the  patient  is  then  radiographed  at  frequent  intervals  there- 


THE  STOMACH,  LIVER,  AND  PANCREAS 


359 


after  in  search  of  departures  from  the  normal  shape  assumed  by  the 
bismuth  shadow  under  these  conditions  and  corresponding  to  the 
outline  of  the  stomach's  interior  during  peristalsis.  If  the  patient  is 
radiographed  lying  down,  great  care  should  be  taken  to  avoid  pressure 
upon  the  stomach  through  the  abdominal  wall.  By  such  pressure 
the  gastric  shadow  may  be  so  deformed  as  to  simulate  hour-glass 
stomach  and  other  abnormalities.  The  tube  is  to  be  focussed  in  all 
cases  upon  the  third  lumbar  vertebra,  and  neither  this  focus  nor  the 


D 


Fig.  209b. — Radiograph    of    Stomach  After  Bismuth-  Meal.     P.  Pylorus.     A.  Loss  of 
outline  due  to  score  and  exudate  from  chronic  ulcer.     D.  Duodenum. 


patient's  position  must  change;  great  distortion  of  the  picture  and 
many  false  inferences  result  from  failure  to  follow  these  rules. 

In  a  satisfactory  picture  of  the  stomach  one  should  be  able  to  make 
out  the  unbroken  outline  of  the  organ  indented  only  by  one  or  two 
contraction  waves.  The  pyloric  sphincter  and  portion  of  bismuth 
just  beyond  it  in  the  duodenum  (the  "Bishop's  cap  ")  should  be  visible 
(see  Fig.  209a) .  If  these  are  not  to  be  made  out,  or  if  there  is  a  marked 
interruption  of  the  normal  outline  of  the  stomach  shown  in  the  same 
place  in  all  the  plates  taken,  cancer  or  ulcer  may  be  suspected  (see 
Fig.  209b. 

The  changes  to  be  found  in  peptic  ulcer  are  not  yet  thoroughly 
worked  out  though  in  most  cases  a  bismuth  residue  is  visible  at  the 
end  of  six  hours,  and  this  fact,  together  with  the  history  and  the  other 
data  of  physical  and  chemical  examination  may  be  of  value.  The 
radiographs  supposed  to  show  bismuth  deposited  in  the  floor  of  an 
ulcer  are  doubted  by  some  of  the  best  experts. 


360  PHYSICAL  DIAGNOSIS 

5.  Incidence  and  Diagnosis  of  Gastric  Diseases. 
In  the  wards  of  the  Massachusetts  General  Hospital  the  number  of 
cases  apparently  of  gastric  disease  treated  between  1870  and  1905  was 
as  follows: 

Cancer 403 

Ulcer 536 

Dilatation 170 

D3'spepsia' 1,002 

Total 2,111 

The  data  at  our  disposal  are  as  follows: 

1.  The  history. 

2.  The  local   and  external   examination  of  the  epigastric  region. 

3.  The  estimation  of  the  size  and  motor  power  of  the  stomach. 

4.  The  examination  of  the  gastric  contents. 

(a)  In  advanced  cancer  of  the  stomach  we  have  pain,  emaciation, 
anaemia,  symptoms  of  fermentation  (see  page  361),  often  dilatation 
and  motor  insufficiency  due  to  pyloric  stenosis,  sometimes  absence  of 
HCl  in  the  gastric  contents  (only  eighty  out  of  six  hundred  and  fifty 
cases  reported  from  the  Mayos'  clinic  by  Graham  and  Guthrie  showed 
no  HCl),  and  in  about  two-thirds  of  the  cases  the  presence  of  digested 
blood  ("coffee  grounds")  in  the  gastric  contents  and  occult  blood 
(guaiac)  in  the  faeces.  But  without  the  presence  of  an  epigastric 
tumor  all  these  facts  are  insufficient  for  diagnosis.  Even  the  tumor 
itself  may  deceive  us,  as  the  adhesions  around  a  gastric  ulcer  may 
present  a  similar  mass  to  the  palpating  hand. 

The  age  of  the  patient  is  of  great  importance,  especially  if  during 
the  earlier  decades  of  life  he  has  been  totally  free  from  gastric  symp- 
toms. Any  type  of  dyspepsia,  any  sort  of  genuine  gastric  trouble,'-^ 
occurring  in  a  person  over  forty  who  has  never  had  any  such  trouble  before, 
is  strongly  suggestive  of  cancer. 

{b)  Peptic  Ulcer,  gastric  or  duodenal. — Physical  examination  usually 
shows  us  very  little.  The  diagnosis  rests  upon  the  history.  Contrary 
to  the  usual  belief  HCl  is  normal  or  subnormal  in  nearly  three-fourths 
of  the  cases.  Occult  blood  is  occasionally  found  and  the  stomach  may 
show  stasis.  The  vomiting  of  blood  is  infrequent  (about  twenty-five 
per  cent). 

(c)  Pure  functional  hyperacidity  is  not  common  but  may  produce 
symptoms   indistinguishable  from   those   of  ulcer. 

^  I.e.,  cases  of  painful  digestion  including  anomalies  of  motion,  sensation,  secretion, 
"gastritis"  and  "gastric  catarrh,"  but  without  evidence  of  ulcer,  cancer,  or  dilatation. 
^  We  must  be  careful  to  exclude  angina  pectoris  as  well  as  gall  stones  and  their  effects. 


THE  STOMACH,  LR'ER,  AND  PANCREAS  361 

(d)  Hypoacidity  and  achylia  gastrica  are  not  characteristic  of  any 
gastric  disease.  They  are  common  in  alcoholism,  in  all  types  of  anaemia, 
in  tuberculosis,  diabetes,  and  nephritis,  as  well  as  in  gastric  cancer. 

(c)  Gastric  dilatation,  when  considerable,  is  almost  always  second- 
ary to  pyloric  obstruction  (due  to  cancer,  cicatrix,  or  adhesions) . 
Symptoms  suggesting  it  are  the  vomiting  at  one  time  of  a  large  quan- 
tity— a  quart  or  more — of  stomach  contents,  often  containing  frag- 
ments of  food  eaten  more  than  eight  hours  previously.  Such  attacks 
of  vomiting  occur  usually  not  after  every  meal,  but  at  longer  intervals. 
It  is  to  be  positively  diagnosed  by  passing  a  tube  and  distending  the 
stomach  with  air  or  water. 

(/)  Gastric  stasis  occurs  with  more  or  less  constancy  in  almost 
every  disease  of  the  stomach  and  in  many  general  constitutional 
diseases  (tuberculosis,  anaemia,  general  debility).  It  constitutes  what 
is  usually  referred  to  by  patients  as  "indigestion,"  "dyspepsia,"  or 
"sour  stomach."  Fermentation  of  stomach  contents  too  long  retained 
is  the  essential  point.  This  results  in  a  sense  of  weight  and  pressure 
in  the  epigastrium,  eructations  of  gas  and  of  sour  or  burning  fluids, 
loss  of  appetite,  nausea,  and  vomiting.  The  tongue  is  generally 
furred  and  the  bowels  are  constipated.  Headache,  vertigo,  and  depres- 
sion of  spirits  often  accompany  it. 

The  Liver. 

The  Massachusetts  General  Hospital  records  (i 870-1 905)  show  the 
following  figures  bearing  on  the  incidence  of  diseases  of  the  liver : 

Passive  congestion 1,288 

Portal  cirrhosis 234 

Biliary  cirrhosis  (Hanot's) o 

Cancer  of  the  Uver 184 

Sarcoma  of  the  liver 2 

Abscess  of  the  liver 51 

Leukaemic  infiltration 46 

Pseudoleukaemic  infiltration 10 

Amyloid  infiltration 9 

Fatty  infiltration 6 

Hydatid  cyst 8 

Syphihs 8 

"  Simple  cyst" 6 

Actinomycosis 3 

Acute  yellow  atrophy 2 

Tuberculosis i 

Total i,8q8 


362  PHYSICAL  DIAGNOSIS 

Diseases  of  the  Gall  Bladder  and  Bile  Ducts. 

Cholelithiasis 457 

Acute  cholecystitis no 

Catarrhal  jaundice 125 

Cancer  of  gall-bladder  or  ducts 47 

Cholangitis ! 9 

Total 701 

The  evidences  of  liver  disease  may  be  either  local  or  general. 

Local  signs  include :  (a)  Pain  and  tenderness  in  the  hepatic  region. 
(&)  Enlargement  of  the  organ,  symmetrical  or  irregular,  (c)  Atrophy 
of  the  organ. 

The  general  signs  which  assist  in  the  diagnosis  of  liver  disease  are: 
{d)  Portal  obstruction,  {e)  Jaundice,  including  changes  in  the  color 
of  the  skin,  mucous  membranes,  and  excretions.  (/)  Loss  of  flesh  and 
strength,  (g)  Evidences  of  infection  (fever,  leucocytosis,  chills, 
sweats,  anorexia).  Qi)  Cerebral  symptoms  (headache,  vomiting, 
depression,  delirium,  convulsions,  coma). 

The  various  attempts  to  test  the  liver  functions  by  chemical 
examination  of  urine  and  faeces  {e.g.,  alimentary  levulosuria)  have  not 
as  yet  been  successful;  hence  all  diagnoses  of  liver  disease  must  be 
built  up  of  the  above  eight  groups  of  data. 

(a)   Hepatic  Pain. 

This  forms  little  or  no  part  of  many  cases  of  liver  disease,  since  it 
occurs  only  when  the  capsule  is  stretched  or  its  nerves  are  involved  in  a 
perihepatitis.  Many  cases  of  hepatic  abscess,  for  example,  run  their 
course  without  pain  or  become  painful  only  when  the  pus  burrows  to 
the  surface  and  stretches  the  capsule.  Besides  this  capsule  pain  in 
liver  disease,  we  have  shoulder  pain  referred  to  the  region  of  the  right 
scapula,  less  often  to  other  parts  of  the  back.  Capsule  pain  is  most 
noticeable  in  cancer  of  the  liver;  shoulder  pain  in  abscess. 

Tenderness  is  present  in  the  same  cases  which  are  painful,  i.e.,  those 
in  which  there  is  perihepatitis  or  stretching  of  the  capsule  by  rapidly 
increasing  tension  from  within.  The  latter  condition  is  commonest  in 
passive  congestion,  but  is  not  characteristic  of  any  single  disease. 

(6)   Enlargement  of  the  Liver. 

Tumors  behind  the  liver,  pushing  it  forward  and  down,  are  often 
overlooked,  because  they  bring  the  liver  so  prominently  into  the  fore- 


THE  STOMACH,  LIVER,  AND  PANCREAS  363 

ground  and  fasten  our  attention  on  what  is  mistaken  for  an  enlarge- 
ment of  the  organ.  Wherever  the  cause  of  a  supposed  enlargement 
of  the  liver  is  not  obvious,  retroperitoneal  sarcoma  or  some  other  deep- 
seated  tumor  should  be  suspected. 

I  have  already  alluded  to  the  possibility  of  mistaking  the  enlarged 
liver  for  empyema,  and  vice  versa  (see  above,  page  329). 

We  are  sure  of  an  increase  in  the  size  of  the  liver  only  when  we  can 
feel  its  edge  below  the  ribs  and  can  determine  by  percussion  that  its 
upper  border  is  not  depressed.^  To  feel  the  edge  of  the  liver,  hook  the 
fingers  of  both  hands  around  the  margin  of  the  right  ribs  and  ask  the 
patient  to  take  a  deep  breath.  At  the  height  of  inspiration  an  edge 
may  be  felt  to  descend  against  the  fingers  and  to' push  its  way  beneath 
them.  Unless  an  edge,  either  sharp  or  rounded,  is  felt,  one  cannot  be 
sure  of  hepatic  enlargement,  for  percussion  of  the  lower  edge  of  the 
liver  is  notoriously  unreliable.  Dulness  below  the  costal  margin  is 
frequently  found  in  cases  without  hepatic  enlargement,  and  should 
never  be  relied  on  unless  the  liver  can  be  felt. 

The  long,  smooth  edge  of  the  liver  descending  one  to  two  inches 
with  full  inspiration  is  rarely  mistaken  for  anything  else,  but  if  the 
edge  is  irregular  and  the  surface  nodular  (see  below)  it  may  be  hard  to 
distinguish  liver  from  stomach  or  possibly  kidney. 

If  ascites  is  present,  the  presence  and  dimensions  of  an  enlarged 
liver  beneath  the  fluid  can  sometimes  be  made  out  by  dipping  (see 
above,  page  344).  If  this  is  impossible,  the  ascites  may  be  tapped, 
after  which  it  is  usually  easy  to  feel  any  enlargement  that  is  present, 
as  the  belly  walls  are  very  flaccid. 

The  causes  of  hepatic  enlargement  (in  adults-),  arranged  approxi- 
mately in  the  order  of  frequency,  are : 

1.  Passive  congestion  (later  stages  of  uncompensated  heart  dis- 
ease) . 

2.  Obstructive  jaundice  (from  any  cause). 

3.  Cirrhosis. 

4.  Fatty  liver,  including  "infiltration"  and  "degeneration." 

5.  Malignant  disease. 

6.  Syphilis  of  the  liver  (congenital  or  acquired) . 

*  A  normal  liver  may  be  pushed  down  by  air,  water,  or  solid  tumors  in  the  lung  and 
pleura,  so  as  to  be  palpable  below  the  ribs;  but  the  evidence  of  a  cause  and  the  low  position 
of  the  upper  border  usually  make  diagnosis  easy. 

^  In  infants,  rickets,  anEemia,  and  gastro-intestinal  disturbances  often  produce  hepatic 
enlargement,  though  the  splenic  enlargement  is  usually  much  greater.  (The  infant's  liver 
is  normally  J  inch  below  the  ribs  in  the  nipple  line.) 


364  PHYSICAL  DIAGNOSIS 

7.  Abscess  of  the  liver. 

8.  Leukaemia  and  pseudoleuksemia. 

9.  Cholangitis. 

10.  Amyloid. 

11.  Hydatid  cysts. 

The  largest  livers  are  found  in  malignant  disease,  biliary  cirrhosis, 
and  abscess. 

In  passive  congestion  the  liver  is  very  tender,  and  the  presence  of 
uncompensated  heart  disease^  usually  makes  the  diagnosis  easy. 
The  surface  of  the  organ  is  smooth  and  firm. 

In  cirrhosis  a  distinction  must  be  drawn  between  (a)  latent  or 
compensated  cases,  wholly  without  symptoms,  and  (6)  uncompensated 
cases,  in  which  diagnosis  depends  on  the  chronic  enlargement  without 
any  considerable  increase  under  observation,  associated  with  evidence 
of  portal  or  biliary  obstruction  {or  both)  and  without  much  pain  or 
irregularity  of  the  liver.  Eighty  per  cent  of  the  two  hundred  and 
thirty-four  cases  recorded  at  the  Massachusetts  General  Hospital 
showed  enlargement,  and  only  twelve  per  cent  showed  pain  (c/. 
Malignant  Disease,  below). 

The  fatty  liver  is  soft  and  smooth  in  feel.  The  presence  of  phthisis 
or  alcoholism  makes  us  suspect  this  diagnosis,  which  depends  largely 
on  excluding  other  causes  of  enlargement. 

Malignant  disease  of  the  liver  (cancer  or  sarcoma)  is  usually  sec- 
ondary to  new  growth  elsewhere.  The  liver  grows  rapidly  under 
observation,  is  usually  painful  (80  per  cent  of  168  Massachusetts 
Hospital  cases)  and  nodular.  Jaundice  and  irregular  fever  are  present 
in  over  one-half  of  the  cases  (54  and  62  per  cent  respectively),  and  the 
loss  of  flesh  and  strength  is  marked. 

Obstructive  jaimdice  (due  to  stone,  stricture,  catarrh,  or  tumor  of 
the  bile  ducts,  or  to  any  other  cause)  often  produces  an  enlarged  liver. 
Diagnosis  depends  on  the  evidence  of  a  cause  for  the  obstruction  and 
the  absence  of  hepatic  nodules,  pain,  or  a  rapid  increase  in  the  size  of 
the  organ. 

Syphilitic  liver  may  be  distinguishable  from  cirrhosis  or  from 
malignant  disease  only  by  the  Wassermann  test  and  therapeutic  test. 
The  history  or  present  evidences  of  alcoholism  or  of  syphilis  are 
important  factors  in  diagnosis,  but,  since  syphilis  may  simulate  the 
nodular  liver  of  malignant  disease  or  the  general  enlargement  and 
portal  stasis  of  cirrhosis,  it  is  essential  to  give  antisyphilitic  treatment 
in  all  doubtful  cases  of  liver  disease. 

^  Either  primary  or  resulting  from  chronic  bronchitis  and  emphysema. 


THE  STOMACH,  LIVER,  AND  PANCREAS  365 

Abscess  of  the  liver  produces  enlargement,  pain,  fever,  leucocytosis, 
and  chills  in  typical  cases,  but  any  of  these  symptoms  may  be  absent 
and  diagnosis  is  often  difficult.  Pain  is  usually  absent.  The  presence 
of  a  possible  cause  (amoebic  dysentery,  appendicitis)  is  important 
evidence.  The  enlargement  is  more  apt  to  be  upward  and  to  the  right 
than  in  other  liver  diseases,  since  the  pus  usually  starts  in  the  right 
lobe  and  burrows  upward.  Hence  many  cases  are  mistaken  for 
empyema  (see  above,  page  329).  Should  swelling  or  fluctuation  ap- 
pear externally  the  diagnosis  is  usually  obvious,  but  in  most  cases  this 
does  not  occur.  Whenever  fever,  leucocytosis  and  dulness  in  the 
right  lower  back  appear  after  an  appendix  operation  with  drainage, 
after  a  dysentery,  or  after  long  continued  biliary  obstruction  (gall 
stone),  hepatic  abscess  should  be  suspected.  As  a  rule  the  diagnosis  is 
made  on  the  etiology  rather  than  on  physical  signs. 

Soft  new  growths  and  syphilis  may  be  almost  indistinguishable 
from  abscess  by  local  signs,  but  jaundice  is  much  commoner  in  malig- 
nant disease  and  the  liver  of  syphilis  is  often  irregular.  The  history 
is  of  value. 

Suppurative  cholangitis,  subphrenic  abscess,  and  pylephlebitis  give 
us  practically  the  same  symptoms  as  hepatic  abscess. 

Amyloid  liver  is  recognized  by  the  presence  of  an  appropriate 
cause  (chronic  suppuration  or  syphilis)  and  the  evidence  of  amyloid 
in  other  organs  (enlarged  spleen,  albuminuria,  diarrhoea).  The  liver 
is  smooth,  not  irregular  as  in  hepatic  syphilis. 

The  leukcemic  liver  is  recognized  by  blood  examination ;  the  pseudo- 
leukgemic  liver  by  the  normal  blood  and  the  histological  examination 
of  the  glandular  enlargements  which  always  accompany  it. 

Hydatid  cyst  is  rarely  to  be  diagnosed  by  physical  signs.  The 
history  of  a  residence  in  Australia,  Iceland,  certain  parts  of  Germany 
or  of  the  British  Isles,  is  important  evidence,  since  the  disease  has 
never  been  known  to  originate  in  North  America.  Physical  examina- 
tion may  enable  us  to  make  out  that  the  hepatic  enlargement  is  due  to 
a  cystic  tumor,  tense  and  elastic,  with  notable  absence  of  constitutional 
disturbances  (Rolleston). 

(c)   A  trophy  of  the  Liver. 

Diminution  in  the  size  of  the  liver  can  hardly  ever  be  demonstrated 
satisfactorily  during  life,  since  we  must  rely  upon  percussion  for  our 
evidence,  and  percussion  of  the  upper  and  of  the  lower  border  of  the 
liver  may  be  rendered  difficult  by  distention  of  the  lung  (emphysema) 


366  PHYSICAL  DIAGNOSIS 

or  of  the  colon.  Atrophy  may  be  recognized  in  a  small  proportion  of 
the  cases  of  hepatic  cirrhosis  and  in  acute  yellow  atrophy,  but  is  rarely 
recognized  in  either  condition.  The  rapidly  fatal  course  of  the  latter 
disease  with  jaundice  and  a  "typhoidal  state"  contrasts  with  the 
prolonged  portal  stasis  characteristic  of  cirrhosis. 

{d)   Portal  Obstruction. 

A  characteristic  group  of  signs  manifest  the  presence  of  an  obstacle 
to  the  flow  of  blood  through  the  portal  system.     This  group  includes: 

1.  Haematemesis  and  dyspepsia. 

2.  Ascites^  (see  page  347). 

3.  Splenic  enlargement.^ 

4.  Collateral  dilatation  of  the  abdominal  veins  (rarely  seen  in  life) . 
Hcematemesis  is  usually   due   to   rupture   of   dilated   oesophageal 

veins,  occasionally  to  gastritis. 

Splenic  enlargement  is  more  marked  in  the  rare  cases  associated 
with  chronic  jaundice  {biliary  cirrhosis)  and  without  ascites. 

The  cause  of  portal  obstruction  is:  i.  Cirrhosis,  in  ninety-five  per 
cent  of  the  cases.  The  remaining  five  per  cent  is  made  up  of:  2. 
Obliterations  of  the  portal  vein,  usually  by  thrombosis  or  tumors. 

(e)  Jaundice. 

The  yellew  staining  of  sclera,  skin,  and  mucous  membranes,  with  or 
without  changes  in  the  color  of  the  urine  and  faeces,  is  known  as  jaun- 
dice. I  have  classed  it  as  a  general  rather  than  a  local  sign  of  liver 
disease,  because  it  may  occur  from  toxaemia  and  independent  of  any 
lesion  of  the  liver;  for  instance,  in  septicaemia,  malaria,  yellow  fever, 
and  pernicious  anaemia.  It  is  true,  nevertheless,  that  all  jaundice  is 
due  ultimately  to  obstruction  in  the  path  of  the  bile  stream.  In  the 
toxsemic  cases  the  obstruction  is  due  to  inflammation  of  some  of  the 
small  ducts  within  the  liver.  In  the  cases  due  to  stone  or  cancer  the 
obstruction  is  in  the  larger  bile  ducts,  usually  the  common  duct. 

Causes  of  Jaundice. — The  four  types  most  often  seen  are: 

1.  Jaundice  of  the  new-born  (occurs  in  from  thirty  to  eighty  per 
cent  of  all  children). 

2.  Catarrh  of  the  bile  ducts  ("catarrhal  jaundice"). 

3.  Gall  stones,  especially  in  the  common  duct. 

4.  Cancer    (pancreas,  glands,   liver,  gall   bladder,  or   bile   ducts). 

'  Ascites  and  splenic  enlargement  are  not  purely  mechanical  phenomena.     Toxaemia 
and  sometimes  chronic  peritonitis  or  cardiac  failure  contribute. 


THE  STOMACH,  LIVER,  AND  PANCREAS  367 

Less  common  are  the  cases  due  to* 

5.  Cirrhosis  of  the  Uver. 

6.  Syphilis  of  the  Hver. 

7.  Infectious  disease  or  toxaemia. 
Rare  causes  are: 

8.  Acute  yellow  atrophy,  with  or  without  phosphorus  poisoning. 

9.  Weil's  disease  and  other  types  of  infectious  jaundice. 

10.  Congenital  obliteration  of  the  bile  ducts. 

11.  Family  hemolytic  jaundice. 

The  results  of  jaundice  upon  the  body  are  chiefly  the  following: 
(a)  Slow  pulse  (often  below  60) .  {b)  Itching  of  the  skin,  (c)  Mental 
depression,  {d)  Hemorrhagic  tendency  (which  renders  operation 
dangerous) . 

In  mild  cases  there  is  no  bile  in  the  urine;  in  severe  cases  it  is  almost 
always  present.  The  stools  are  gray  or  clay-colored  when  the  obstruc- 
tion is  in  the  larger  bile  ducts  outside  the  liver,  but  in  the  toxaemic 
forms  of  jaundice  abundance  of  bile  passes  into  the  intestine  and  the 
stools  are  of  normal  color. 

Diagnosis  of  the  cause  of  jaundice  depends  on  the  following  con- 
siderations : 

1.  If  it  occurs  during  the  first  four  days  of  life  without  any  other 
symptom  and  passes  off  within  a  few  weeks,  we  call  it  simple  jaundice 
of  the  new-horn. 

2.  If  the  attack  is  preceded  by  gastro-intestinal  disturbances, 
usually  in  a  young  person,  if  pain  and  hepatic  enlargement  are  slight 
or  absent,  and  if  the  jaundice  passes  off  within  six  weeks,  we  term  it 
"  catarrhal  jaundice''  (though  the  pathology  of  this  and  of  the  preceding 
condition  is  unknown) . 

3.  If  there  have  been  attacks  of  biliary  colic  (see  below,  page  369), 
intermittent  fever  with  intervals  of  good  health,  and  no  considerable 
or  progressive  enlargement  of  the  liver  or  gall  bladder,  stone  in  the 
common  duct  is  probably  the  diagnosis. 

4.  Cancer  of  the  pancreas,  duodenal  papilla,  gall  bladder,  bile 
ducts,  or  of  the  glands  at  the  hilus  of  the  liver,  produces  enlargement 
of  the  gall  bladder,  and  a  jaundice  usually  painless  but  of  the  intensest 
type  known.  Loss  of  flesh  and  strength  is  rapid.  Cancer  of  the  liver 
itself  gives  a  rapidly  enlarging,  nodular  liver  with  steady  pain,  and, 
in  fifty  per  cent  of  cases,  jaundice. 

5.  In  ordinary  portal  cirrhosis  the  jaundice  is  less  intense  and 
permanent,  portal  stasis  is  usually  evident,  and  there  is  generally  a 
moderate  enlargement  of  the  liver. 


368  PHYSICAL  DIAGNOSIS 

6.  Enlargement  of  the  liver  with  jaundice  lasting  for  years  in 
young  people  is  probably  due  to  biliary  cirrhosis,  or  family  hemolytic 
jaundice. 

7.  Hepatic  syphilis  produces  jaundice  in  a  small  percentage  of 
cases,  and  under  these  conditions  is  so  apt  to  be  mistaken  for  cancer 
that  I  think  in  all  cases  supposed  to  be  cancer  in  or  near  the  liver  a 
Wasserman  reaction  should  be  tried  and  a  course  of  antisyphilitic  treat- 
ment given.  Other  lesions  or  symptoms  of  syphilis  will  naturally 
influence  us. 

8.  The  jaundice  secondary  to  septicaemia,  yellow  fever,  malaria, 
and  pernicious  anaemia  is  usaully  slight  and  rarely  shows  in  the  urine 
or  bleaches  the  stools.  The  evidence  of  the  anemia  or  of  an  infection 
makes  evident  the  nature  of  the  jaundice. 

9.  Acute  yellow  atrophy  cannot  be  determined  without  autopsy. 
Its  chief  symptoms  are  given  in  its  name. 

10.  Weil's  disease  is  the  term  applied  to  some  or  all  of  the  groups 
of  infections  of  unknown  origin  which  are  accompanied  by  jaundice. 
From  catarrhal  jaundice  it  is  to  be  distinguished  during  life  only  by 
convincing  evidence  of  general  infection. 

Congenital  obliteration  of  the  biliary  ducts  is  suggested  by  the 
occurrence  of  congenital,  intense,  and  permanent  jaundice  with 
hemorrhage  and  enlargement  of  the  liver  and  spleen.  In  some  of  the 
cases  of  this  group  the  red  cells  can  be  shown  to  possess  an  exag- 
gerated vulnerability,  and  the  blood  serum  may  have  unusual  auto- 
hemolytic  powers.     Several  such  cases  may  occur  in  a  single  family. 

(/)   Loss  of  Flesh  and  Strength 

in  cases  presenting  other  signs  of  liver  disease  is  commonest  in  uncom- 
pensated cirrhosis  and  in  malignant  disease,  but  may  occur  in  gall- 
stone disease,  syphilis,  or  abscess.  I  have  known  a  physician  greatly 
alarmed  at  his  own  rapid  emaciation,  though  his  symptoms  (jaundice 
and  colic)  pointed  to  stone  in  the  common  duct  and  operation 
proved  this  diagnosis  correct. 

(g)    The  Infection  Group  of  Symptoms. 

These  symptoms — viz.,  fever,  chills,  sweats,  leucocytosis,  disturb- 
ances of  digestion  and  sleep — are  oftenest  seen  in:  i.  Cholangitis. 
2.  Hepatic  abscess.^     3.   "Ball-valve"    or    "floating"    stone    in    the 

'  With  or  without  pylephlebitis. 


THE  STOMACH,  LIVER,  ADD  PANCREAS  369 

common  duct.  In  the  last  disease  jaundice  is  usually  present;  in  the 
others  usually  absent.  In  cancer  of  the  liver  fever  and  leucocytosis 
are  often  present,  but  the  other  signs  of   infection   are  rarely  seen. 

(h)    The  Cerebral  Symptoms  of  Liver  Disease. 

These  vary  from  simple  depression  and  apathy  to  delirium,  con- 
vulsions, and  coma.  Severe  symptoms  are  oftenest  seen  at  the  end  of 
uncompensated  cirrhotic  cases;  eighty-two  per  cent  of  our  fatal  cases 
showed  during  the  last  days  of  life  symptoms  indistinguishable  from 
those  of  uraemia. 

The  Gall  Bladder  and  Bile  Ducts. 

(a)  Biliary  colic,  and  (6)  enlarged  gall  bladder,  with  or  without 
tenderness  and  pain,  are  the  data  on  which  (with  the  evidence  of  local 
or  general  infection,  cachexia,  intestinal  obstruction,  and  jaundice) 
our  knowledge  of  gall-bladder  disease  is  built  up.  In  some  cases 
puzzling  digestive  symptoms  closely  resembling  those  of  duodenal 
ulcer  are  present. 

Differential  Diagnosis  of  Biliary  Colic. 

Biliary  colic,  due  to  impaction  of  a  gall  stone  in  the  cystic  or 
common  duct,  is  a  sudden  pain  in  the  gastric  or  hepatic  region,  radiat- 
ing thence  in  all  directions,  but  especially  to  the  right  shoulder, 
scapula  or  back,  with  fever,  chills,  and  vomiting.  In  most  cases  the 
attack  lasts  from  three  to  twelve  hours  (Rolleston)  unless  relieved  by 
morphine.  The  pains  may  be  of  any  degree  of  severity,  and  are  often 
accompanied  and  followed  by  tenderness  over  the  hepatic  region  and 
right  hypochondrium.  The  liver  or  gall  bladder  is  seldom  palpable. 
Jaundice  precedes  or  follows  the  attack  in  about  one-half  of  the  cases. 

Renal  colic  differs  in  that  it  usually  starts  over  the  kidney  (in  the 
back)  and  radiates  down  the  ureter,  while  the  urine  is  apt  to  be  bloody 
but  free  from  bile. 

Floating  kidney  with  kinked  ureter  may  produce  pains  which 
cannot  in  themselves  be  distinguished  from  biliary  colic.  The  palpa- 
tion of  the  floating  kidney  may  be  all  that  makes  us  suspect  that  organ 
to  be  the  cause  of  suffering. 

Peptic  ulcer  (gastric  or  duodenal)  produces  sharp,  paroxysmal 
pain,  but  this  usually  comes  several  hours  after  a  meal,  can  be  relieved 
by  food,  vomiting,  lavage,  or  alkalies,  and  produces  no  fever,  chill,  or 

24 


370  PHYSICAL  DIAGNOSIS 

sweat.  Hyperchlorhydria  may  produce  similar  pain  at  night  (the 
commonest  time  for  biliary  colic),  but  is  relieved  by  food  or  alkali. 

Lead  colic  is  almost  always  associated  with  lead  dots  in  the  gums 
and  stippling  of  the  red  corpuscles  (see  pages  24  and  442).  The 
history  of  work  as  a  painter  or  plumber  and  the  absence  of  tenderness 
assist  the  diagnosis. 

Gastric  Crises  in  Tabes  are  not  infrequently  operated  on  under  a 
false  diagnosis  of  gall  stones.  Study  of  the  reflexes  should  prevent 
such  a  mistake. 

Enlarged  Gall  Bladder. 

An  enlarged  gall  bladder  cannot  be  felt  unless  it  is  stretched  tight 
by  its  contents;  a  very  tense  gall  bladder  may  be  palpable  without  much 
enlargement.  Probably  most  enlarged  gall  bladders  are  not  tense, 
and  so  cannot  be  made  out  without  operation.  When  palpable  the 
organ  presents  as  a  smooth,  rounded,  pear-shaped  tumor  at  the 
margin  of  the  ribs  in  the  nipple  line. 

The  causes  of  enlargement  are: 

(a)  Stone  in  the  cystic  duct,  at  the  neck  of  the  gall  bladder. 

(6)  Cancer  of  the  pancreas  or  other  tumor  obstructing  the  common 
duct  from  without.^ 

(c)    Cholecystitis. 

In  the  first  of  these  jaundice  is  rarely  present  (ten  to  fifteen  per 
cent — RiedeP) ,  and  colic  with  or  without  palpable  tumor  is  our  guide 
to  diagnosis. 

In  cancerous  obstruction  there  is  intense  and  permanent  jaundice. 

In  cholecystitis  there  is  usually  no  jaundice,  but  all  the  signs  of 
local  and  general  infection — pain,  tenderness,  leucocytosis ,  send  fever — 
are  present.  In  acute  cases  the  symptoms,  however,  may  be  indis- 
tinguishable from  those  of  appendicitis,  since  the  pain  may  be  referred 
to  the  navel  or  even  to  the  appendix  region.  Many  mistakes  of 
diagnosis  between  appendicitis  and  acute  cholecystitis  occur,  and 
must  occur  until  our  present  diagnostic  resources  are  increased. 

Results  of  Cholecystitis. 

(a)  Adhesions  about  the  gall  bladder  may  involve  the  duodenum  or 
pylorus,  and  produce  kinking  and  consequent  dilatation  of  the  stomach 
and  chronic  dyspepsia. 

^  Courvoisier  has  shown  that  if  the  common  duct  is  obstructed  by  a  gall  stone  the  gall 
bladder  is  very  rarely  enlarged. 

^  Riedel:  BerHn.  khn.  Woch.,  1901,  No.  3. 


THE  STOMACH,  LIVER,  AND  PANCREAS  371 

(b)  Intestinal,  obstruction  (see  below,  page  377)  is  occasionally 
produced  by  the  ulceration  of  a  large  gall  stone  from  the  gall  bladder 
into  the  intestine,  usually  the  small  intestine  or  duodenum. 

The  Pancreas. 

Diseases  of  the  pancreas  can  very  rarely  be  diagnosed  by  our 
present  methods.  If  greatly  enlarged  (tumor,  cyst,  hemorrhage)  it 
may  become  palpable  as  a  deep  epigastric  tumor,  but  we  are  rarely 
able  to  differentiate  such  tumors  from  those  of  the  retroperitoneal 
structures. 

Indirect  and  uncertain  information  is  afforded  by  the  presence  in 
the  urine  of  sugar  or  fat-splitting  ferments^  and  in  the  stools  by  the 
appearance  of  an  abnormal  amount  of  muscle  fibre  or  oi  fat  not  other- 
wise to  be  accounted  for  {i.e.,  in  the  absence  of  jaundice,  diarrhoea, 
tuberculous  peritonitis,  or  large  meals  of  fat) . 

Cancer  of  the  pancreas  may  sometimes  be  suspected  on  account  of 
its  pressure  effects.  Intense  and  permanent  jaundice  with  enlarged 
(perhaps  palpable)  gall  bladder  and  liver  may  be  due  to  the  pressure 
of  cancer  in  the  head  of  the  pancreas  upon  the  common  bile  duct. 
Ascites  and  swelled  legs  may  be  produced  by  compression  of  the 
inferior  vena  cava.  But  the  diagnosis  can  rarely  be  more  than  a 
suspicion,  for  cancer  of  the  gall  bladder,  ducts,  duodenal  papilla  or 
retroperitoneal  sarcoma  may  produce  similar  pressure  effects.  Should 
these  pressure  effects  coincide  with  a  glycosuria  and  the  presence  of  a 
deep-seated,  almost  immovable  tumor,  the  suggestion  of  pancreatic 
disease  becomes  more  plausible. 

Acute  pancreatic  disease,  hemorrhagic  or  suppurative,  is  not  rec- 
ognizable until  it  is  seen  at  an  operation  undertaken  for  the  relief  of 
some  grave,  acute  lesion  of  the  upper  abdomen.  Perforated  gastric 
ulcer  and  intestinal  obstruction  may  give  identical  symptoms,  viz., 
sudden,  intense,  epigastric  pain  and  tenderness,  with  vomiting  and 
collapse.  One  or  two  days  later  a  tender  epigastric  tumor  may  appear, 
but  this  presents  no  characteristic  peculiarities. 

Pancreatic  cyst  presents  a  very  slow-growing,  possibly  elastic,  deep- 
seated  epigastric  tumor,  which  usually  produces  little  in  the  way  of 

^The  suspected  urine  is  neutralized  with  potassium  hydroxide  and  one  portion  of  it 
boiled  to  destroy  any  ferment  that  may  be  present.  To  this  and  to  the  unboiled  portion 
ethyl  butyrate  is  added.  In  twenty-four  hours  an  acid  reaction  may  appear  in  the  unboiled 
specimen  if  it  contains  a  ferment,  while  the  other  specimen  shows  no  considerable  change  in 
reaction. 


372  PHYSICAL  DIAGNOSIS 

pressure  effects,  and  may  be  associated  with  glycosuria  and  fatty 
stools. 

Bronzed  Diabetes. — The  association  of  diabetes  with  bronzing  of  the 
skin  and  enlargement  of  the  liver  is  strongly  suggestive  of  chronic 
fibrous  pancreatitis. 

In  any  doubtful  case  the  possibility  of  pancreatic  disease  is  in- 
creased; (a)  If  improvement  follows  the  adminstration  of  pancreatic 
preparation;  (6)  if  glycosuria  follows  the  administration  of  loo  gm.  of 
glucose  (alimentary  glycosuria) . 

Incidence  of  Pancreatic  Disease. 

The  following  table  is  from  the  Massachusetts  General  Hospital 
records  (1870-1905): 

Cases 

Cancer  of  the  pancreas • 35 

Acute  pancreatitis 13 

Chronic  pancreatitis 10 

Cyst  of  the  pancreas ^. 3 

Total 61 


CHAPTER  XXI. 
THE  INTESTINE,  SPLEEN,  KIDNEY. 

The  Intestines. 

Incidence  of  Intestinal  Disease  (excluding  diarrhoea  and  constipation) 
at  the  Massachusetts  General  Hospital,    1870- 1905. 

1.  Appendicitis 3i3i4 

2.  Acute  obstruction 142 

3.  Cancer  (above  the  rectum) 155 

4.  Dilated  colon 6 

5.  Tuberculosis 2 

6.  Faecal  impaction  (above  the  rectum) 2 

Total 3,621 

Data  for  Diagnosis. 

The  data  on  which  are  based  all  our  conclusions  regarding  intes- 
tinal disease  are  obtained  from  the  following  sources: 

1.  Pain  (colicky  or  steady)  and  tenderness,  tenesmus. 

2.  Gaseous  distention  and  the  noises  and  sensations  produced  by 
gas. 

3.  Diarrhoea  or  constipation. 

4.  Muscular  rigidity  of  the  belly  wall  protecting  an  intestinal  lesion. 

5.  Tumor,  palpable  or  visible,  and  believed  to  be  connected  with 
the  intestines  (together  with  the  effect  of  catharsis  on  such  tumor). 

6.  Visible  or  palpable  peristalsis  (see  page  339). 

7.  Digital   or   visual   examination   of  the   rectum    (see   page   413). 

8.  Examination  of  the  intestinal  contents,  faecal  and  other  (see  page 

378). 

9.  Inflation  of  the  colon  through  the  rectum  (see  page  345). 

10.  Indicanuria — rarely  of  value. 

11.  Constitutional  manifestations,   such   as  fevers,   vomiting,   leu- 
cocytosis,  emaciation. 

Some  of  these  data  need  further  comment. 

Intestinal  Pain. — Many  pains  associated   with  intestinal  disease 

(appendicitis,  cancer)  are  due  in  fact  to  irritation  of  the  peritoneum. 

Which  of  the  numerous  pains  referred  to  the  belly  should  be  inter- 

373 


374 


PHYSICAL  DIAGNOSIS 


preted  as  intestinal  in  origin?  Those  especially  which  (a)  shift  rapidly 
from  place  to  place;  (6)  accompany  the  noises  and  sensations  of  the 
passage  of  gas  and  faeces  through  the  intestine;  (c)  accompany  diar- 
rhoea or  constipation. 

Tenderness  is  usually  a  symptom  of  peritoneal  rather  than  intes- 
tinal irritation.     With  true  intestinal  pain  {colic)  there  is  often  relief 

by  pressure — the  precise  opposite  of 
tenderness.  Yet  so  close  is  the  asso- 
ciation of  intestine  and  peritoneum 
that  in  appendicitis,  intestinal  ulcera- 
tion, tumors,  and  even  in  simple 
gaseous  distention  of  the  gut,  there  is 
often  local  or  general  tenderness. 
When  extreme  and  associated  with 
constitutional  manifestations — fever, 
leucocytosis,  collapse — it  always  sug- 
gests peritonitis.  When  there  are  no 
constitutional  manifestations,  a  purely 
local  pain  or  tenderness  has  little 
diagnostic  value. 

Tenesmus. — The  desire  to  pass 
another  stool  as  soon  as  one  has 
been  evacuated,  together  with  local 
burning  and  straining,  means  always 
rectal  irritation  (inflammation,  ulcer). 
It  is  one  of  the  most  definite  and 
reliable  symptoms  known. 

Gaseous  distention  of  the  intestine 
is  proved  by  an  increase  of  the  normal 
tympanitic  note  over  part  or  all  of 
the  belly,  together  with  a  prominence 
of  the  overlying  belly  wall.  It  is 
chiefly  and  most  frequently  the  colon  that  produces  distention. 

The  significance  of  distention  is  vague  and  depends  largely  on  the 
associated  data.  In  acute  gastro-intestinal  ''catarrh"  the  diarrhoea 
and  absence  of  severe  constitutional  manifestations  make  us  put  little 
stress  on  the  associated  distention.  In  typhoid  fe-ver  distention  results 
from  atony  of  the  intestinal  walls  and  is  "to  some  extent  a  measure 
of  the  intensity  of  the  local  lesions"  (Osier).  In  intestinal  obstruction 
distention  may  be  extreme  if  the  stoppage  is  low  down  (in  the  colon) , 
less  marked  if  the  lesion  is  high  up. 


Fig.  2IO. — Congenital  dilatation 
pf  colon. 


THE  INTESTINE,  SPLEEN,  KIDNEY  375 

Distention  which  continues  despite  free  purgation  is  very  often  due 
to  chronic  intestinal  obstruction. 

In  starvation,  children  often  get  very  large  bellies,  owing  to  muscu- 
lar atony  of  the  gut  and  the  resulting  gaseous  accumulation.  But  in 
no  case  is  the  distention  of  itself  of  much  diagnostic  value.  The 
associated  symptoms  give  it  significance. 

In  congenital  dilation  of  the  colon  (Hirschsprung's  disease)  a  huge 
belly  is  associated  with  obstinate  constipation.  The  colon  can  be 
measured  and  shown  to  be  dilated  through  the  use  of  bismuth  suspen- 
sions (by  rectum)  and  x-ray.     (See  Fig.  210.) 

Diarrhoea,  the  passage  of  more  and  looser  stools  than  is  normal  for 
the  individual,  is,  like  distention,  a  result  of  many  causes  both  within 
and  outside  the  intestine. 

The  most  important  are: 

(  (a)  Indigestion  (acute  and  chronic) . 
!   (b)  Ulceration  (some  cases  only). 

....  (c)  Cancer  of  the  colon  or  rectum. 

1.  Intestinal  disease.       i   ,  ,.  ^ 

[a)  intussusception. 

(e)  Infectious  diseases  (cholera,  dysentery,  typhoid), 
l  (/)  Intestinal  parasites, 
r  (a)  Nervous  causes  (emotion,  Basedow's  disease,  etc.). 

2.  Outside  influences,     -j   {b)  General  infections  (sepsis). 

I  (c)  Cachectic  states  (anaemias,  nephritis,  etc.). 

By  a  search  for  these  causes,  as  well  as  by  the  use  of  the  data 
obtained  by  examination  of  the  stools,  we  arrive  at  an  understanding 
of  the  diagnostic  significance  of  diarrhoea. 

Aside  from  diarrhoea,  constipation,  and  dysentery,  which  produce 
no  physical  signs  beyond  those  described — distention,  borborygmi, 
pain,  tenderness,  tenesmus,  and  constitutional  manifestations — there 
are  but  three  important^  diseases  of  the  intestines : 

I.  Appendicitis. 

II.  Intestinal  obstruction. 

III.  Cancer  of  the  bowel. 

I.  Appendicitis. 

1.  The  local  signs  are  pain,  tenderness,  muscular  spasm,  and 
tumor. 

2.  The  general  or  constitutional  signs  are  fever,  chill,  rapid  pulse, 
vomiting,  constipation,  frequency  or  cessation  of  micturition,  and 
leucocytosis. 

■'  Tuberculous  enteritis  and  pericjecal  tuberculosis  will  be  briefly  referred  to  later. 


376  PHYSICAL  DIAGNOSIS 

(a)  The  pain  may  be  at  first  epigastric  (pylorospasm  ?)  or  general, 
later  localizing  itself  in  the  right  iliac  fossa,  less  often  near  the  navel,  the 
gall  bladder,  or  in  any  other  part  of  the  belly. 

(b)  The  tenderness  is  more  important  in  diagnosis;  indeed,  without 
tenderness  diagnosis  is  rarely  possible.  It  is  usually  greatest  near  a 
point  half-way  from  the  anterior  iliac  spine  to  the  navel.  Occasionally 
a  tender  point  in  the  pelvis  may  be  reached  by  rectal  or  vaginal 
examination,  but  this  is  not  a  reliable  sign. 

(c)  Muscular  spasm  over  the  appendix  region  is  present  in  most 
cases,  and,  while  it  renders  accurate  palpation  impossible,  it  is  in  itself 
so  characteristic  of  the  disease  that  we  do  not  regret  it. 

Psoas  spasm  occurs  in  a  minority  of  cases.  The  patient  leans  his 
body  forward  and  toward  the  right  in  walking,  or,  if  recumbent,  draws 
up  the  right  thigh  to  relax  the  spasm. 

(d)  Tumor — about  the  size  and  shape  of  a  lemon,  ill-defined  and 
tender — is  felt  in  the  right  iliac  fossa  in  many  cases.  It  may  be 
considerably  larger  and  better  defined  if  abscess  has  existed 
for  several  days,  or  it  may  be  smaller  and  more  sausage-shaped. 
Fluctuation  and  bulging  can  sometimes  be  made  out  by  rectum  or 
vagina. 

(e)  The  constitutional  signs  may  or  may  not  be  marked,  according 
to  the  duration  of  the  process,  its  virulence,  and  the  degree  of  infection 
of  the  peritoneal  cavity.  The  fever  is  usually  moderate,  under  102.2° 
F.,  with  corresponding  elevation  of  the  pulse.  Vomiting  comes  at 
the  outset  if  at  all,  and  is  usually  over  by  the  second  day.  A  leucocyte 
count  which  rises  or  remains  elevated  (above  16,000)  accompanies  the 
active  and  advancing  stages  of  the  disease.  In  cases  that  are  very 
mild  or  tightly  walled  in  by  adhesions,  and  in  cases  with  virulent 
general  peritonitis,  the  leucocytes  may  be  normal  or  subnormal. 

Diagnosis  can  hope  only  to  establish  the  existence  of  a  local  inflam- 
matory process  in  the  abdomen;  acute  cholecystitis  and  acute  pus  tube 
may  present  signs  indistinguishable  from  those  of  appendicitis,  though 
the  site  of  tenderness  often  sets  us  right.  Non-inflammatory  processes, 
such  as  lead  colic,  tabes,  biliary  and  renal  colic,  floating  kidney,  and 
acute  gastro-intestinal  upsets,  can  usually  be  excluded,  since  they  do 
not  show  so  much  local  tenderness,  fever,  and  leucocytosis. 

In  those  who  are  familiar  with  the  symptoms  of  appendicitis,  a 
vivid  imagination  may  conjure  up  a  set  of  sensations  that  are  difficult 
for  the  physician  to  distinguish  from  those  of  the  actual  disease.  Even 
tenderness  may  be  simulated,  but,  by  distracting  the  patient's  atten- 
tion while  we  palpate,  we  may  be  able  to  press  hard  over  the  appendix 


THE  INTESTINE,  SPLEEN,  KIDNEY  377 

without  eliciting  complaint.     The  absence  of  leucocytosis,  the  age  and 
sex  of  the  patient,  also  help  us  to  exclude  appendicitis. 

//.  Intestinal  Obstruction. 

(a)  Acute  Obstruction. — A  person  may  have  had  no  faecal  discharge 
for  a  week  or  even  considerably  longer  and  yet  present  all  the  evidences 
of  good  health.  It  is  only  when  vomiting,  severe  paroxysms  of  pain, 
and  distention  of  the  belly  ensue  that  we  suspect  obstruction.  In  the 
acute  cases  tumor  is  noted  in  only  about  fifteen  per  cent.  In  the 
chronic  cases,  usually  due  to  stricture  or  cancer,  a  faecal  tumor  can 
often  be  felt  and  diarrhoea  be  the  chief  symptom  or  may  alternate  with 
constipation. 

By  physical  signs  alone  I  do  not  believe  that  general  peritonitis 
and  acute  intestinal  obstruction  can  always  be  distinguished.  Fever 
is  not  distinctive  of  general  peritonitis,  for  it  occurred  in  eighty-four 
out  of  one  hundred  and  twenty-two  cases  of  acute  obstruction  in  the 
Massachusetts  Hospital  records,  and  in  forty-three  of  these  cases  free 
fluid  in  the  peritoneal  cavity  was  demonstrated  as  well.  Stercoraceous 
vomiting  may  occur  in  general  peritonitis;  it  was  absent  in  three- 
fourths  of  the  Massachusetts  Hospital  cases  of  obstruction.  Weak, 
rapid  pulse,  cold  extremities,  and  a  drawn,  anxious  face  are  common 
to  both  diseases.  Tenderness  is  more  general  and  more  marked  in 
general  peritonitis  than  in  simple  obstruction,  yet  some  tenderness  was 
complained  of  in  fifty-six  out  of  the  one  hundred  and  twenty-two  cases 
of  obstruction  just  cited. 

On  the  whole,  the  differential  diagnosis  of  these  two  diseases  seems 
to  depend  far  more  on  the  history  and  the  etiology  than  on  physical 
signs. 

(6)  Chronic  Obstruction. — Here  the  diagnosis  is  simpler.  There  is 
usually  a  history  of  increasing  constipation  sometimes  interrupted  by 
occasional  attacks  of  diarrhoea.^  T^imor  is  palpable  in  fifty-eight  per 
cent  of  cases.  Visible  peristalsis  was  recorded  in  seventeen  per  cent, 
of  the  Massachusetts  Hospital  cases.  Distention  is  gradual  and  late, 
but  often  persists  despite  purgation.  Cachexia  is  frequently  present. 
Cancer  of  the  colon,  usually  at  the  sigmoid  or  caecum,  is  the  commonest 
cause.     Stricture,  except  cancerous  stricture,  is  rare. 

(c)  Acute  Obstruction  by  a  Chronic  Lesion. — Cancer  of  the  sigmoid 
often  exists  for  months  almost  latent,  or  produces  only  moderate  con- 
stipation,' so  that  the  patient  considers  himself  well.     Such  cancers 

'  The  latter  combination  occurred  in  si.x  per  cent,  of  the  Massachusetts  Hospital  cases. 


378  PHYSICAL  DIAGNOSIS 

present  an  annular  growth,  hardly  bigger  than  a  signet-ring,  practically 
an  annular  stricture. 

This  stricture  may  be  suddenly  "shut  down"  during  an  acute 
gastro-intestinal  attack,  and  we  are  then  confronted  with  all  the  signs 
of  acute  obstruction.  Only  the  seat  of  the  lesion,  the  age  of  the 
patient,  and  possibly  the  appearance  of  peristaltic  waves  can  lead  us 
aright  in  our  diagnosis  of  the  cause  of  obstruction. 

///.   Cancer  of  the  Bowel. 

The  signs  are  those  of  chronic  intestinal  obstruction  (see  last 
section) .  Occasionally  the  tumor  may  not  produce  much  obstruction, 
and  we  have  simply  pain  and  a  tumor  which  we  find  by  examination 
is  not  attached  to  the  liver,  spleen,  kidney,  or  stomach,  and  usually  is 
about  the  size  of  a  hen's  egg.  If  faeces  have  accumulated  behind  such 
a  tumor,  we  may  feel  larger  masses.  In  my  experience  palpable 
tumors  due  to  faecal  impaction  alone,  without  organic  stricture  or 
cancer,  are  very  rare,  except  in  the  rectum  or  lower  sigmoid;  if  found 
above  this  region  they  are  almost  invariably  dependent  on  stricture  or 
cancer  of  the  bowel. 

Examination  of  Intestinal  Contents. 

1.  Weight. — With  the  average  diet  of  the  adult  "Anglo-Saxon," 
the  weight  of  the  daily  stool  is  from  lOO  to  250  gm.  (about  25  to  70 
gm.  dry)  but  Chittenden  has  shown  that  with  a  low  proteid  diet  of 
2,000-2,750  calories  value,  the  weight  of  the  stool  may  be  less  than 
half  this  amount.^ 

2.  Color. — (a)  White  or  light  yellow — milk  diet,  bread  and  milk  diet. 
(6)    Black — blood,    bismuth    or    iron    (medicinal),    blackberries, 

huckleberries,  red  wine. 

(c)  Green;  some  normal  infants'  stools  after  standing;  fermented 
infant's  stool  if  green  when  passed;  green  vegetables,  calomel. 

(d)  Gray — absence  of  bile  (jaundice),  sometimes  after  cocoa  or 
chocolate. 

(e)  Bloody  red — if  in  small  amount  and  fresh,  usually  due  to 
hemorrhoids;  in  large  amounts  it  may  also  be  due  to  hemorrhoids  or 
to  any  of  the  causes  of  intestinal  ulceration  (typhoid,  cancer,  dysen- 
tery, etc.). 

3.  Odor. — In  adults  of  no  great  significance.  In  infants  foul  stools 
suggest  albuminoid  decomposition,  and  strongly  sour  stools  suggest 
acid  fermentation. 

^  "Physiological  Economy  in  Nutrition,"  1904,  p.  42. 


THE  INTESTINE,  SPLEEN,  KIDNEY  379 

4.  Abnormal  Ingredients. — (a)  Undigested  food  in  small  quantities 
is  present  in  normal  stools,  but  when  digestion  is  faulty  larger  quan- 
tities easily  recognized  by  the  naked  eye  may  occur.  Pieces  of  meat, 
flakes  of  casein  (especially  in  typhoid  patients  overfed  with  milk), 
fragments  of  starchy  food,  and  lumps  of  fat  (steatorrhoea)  may  be  seen. 

The  natural  inference  from  the  presence  of  these  substances  is 
that  the  gastro-intestinal  tract  is  not  at  present  dealing  with  them 
satisfactorily.  Fatty  stools  are  present  in  jaundice,  tuberculosis,  or 
amyloid  of  the  intestine,  and  even  in  simple  catarrh.  Though  often 
associated  with  pancreatic  disease,  fatty  stools  are  by  no  means  char- 
acteristic of  it. 

(6)  Mucus. — Small  shreds  of  mucus  adherent  to  faeces  are  of  no 
importance  and  cause  much  unnecessary  worry  among  anxious 
mothers.  Larger  amounts,  if  intimately  mixed  with  the  stool,  point 
to  catarrh  of  the  small  intestine;  if  mucus  thickly  coats  or  makes  up 
the  bulk  of  the  stool,  the  trouble  is  in  the  colon.  The  latter  is  by  far 
the  commonest  condition.  Anything  from  a  very  mild  to  a  severe 
catarrhal  condition  is  accompanied  by  mucus.  Large  periodic 
discharges  of  mucus  and  shreds  mean  usually  the  neurosis  "colica 
mucosa." 

(c)  Fresh  Blood. — Piles  are  by  far  the  commonest  cause  of  bloody 
stools,  and  the  amount  of  blood  may  be  trifling  or  may  be  large  enough 
to  produce  in  time  a  severe  anaemia. 

Enteritis  (the  mild  follicular  or  the  severe  ulcerative  form)  often 
produces  bloody  stools.  The  associated  symptoms,  diarrhoea,  mucus, 
and  pain,  together  with  the  etiology  (dietetic  error,  typhoid  fever, 
amoeba  coli),  must  determine  the  nature  of  the  enteritis. 

In  cancer  of  the  rectum  or  sigmoid  (rarely  higher  up  in  the  bowel) , 
small  quantities  of  blood,  fresh  or  altered,  are  almost  always  passed 
sooner  or  later.  The  infrequent,  offensive,  and  painful  stools  and  the 
results  of  digital  examination  usually  reveal  the  source  of  the  blood. 

In  intussusception  the  association  of  bloody  stools  with  the  sudden 
appearance  of  a  painful  abdominal  tumor  (usually  in  the  caecal  region) , 
vomiting,  and  severe  constitutional  manifestations  suggest  the 
diagnosis. 

In  hemorrhagic  diseases  (purpura,  scurvy,  acute  leukaemia)  blood 
may  come  from  the  intestine  as  well  as  from  the  other  mucous  mem- 
branes. Other  rare  causes  for  blood  in  stools  are  a  ruptured  aneurism, 
thrombosed  mesenteric  artery,  rectal  syphilis,  or  fissure. 

(d)  Altered  blood  (tarry  stools,  melaena)  follows  the  pouring  out  of 
blood — a  pint  or  more — in  the  upper  gastro-intestinal  tract,  and  occurs 


380  PHYSICAL  DIAGNOSIS 

in  hepatic  cirrhosis,  gastric  or  duodenal  ulcer,  after  severe  nose-bleed, 
and  occasionally  from  other  causes.  Occult  blood,  recognizable  by 
the  guaiac  test,  often  occurs  in  cancer  or  ulcer  of  the  stomach,  and 
forms  an  important  link  in  the  chain  of  evidence  on  which  the  diagnosis 
of  those  diseases  is  based. 

[e)  Pus  is  not  of  great  diagnostic  value.  Large  amounts  mean  the 
breaking  of  an  abscess  (appendix,  pus  tube)  into  the  rectum.  Small 
amounts  occur  in  ulcers  or  even  from  catarrh. 

(/)   Shreds  of  tissue  point  to  ulceration. 

(g)  Gall  Stones. — In  suspicious  cases  break  up  the  faeces  in  a  sieve 
with  plenty  of  water.  The  peculiar,  facetted  shape  of  most  gall  stones 
is  easily  recognized. 

Intestinal  Parasites. 

Bacteria. — Only  the  tubercle  bacillus  can  be  recognized  without 
culture  methods,  which  do  not  fall  within  the  scope  of  this  book. 

For  the  identification  of  tubercle  bacilli  the  following  method  is  to 
be  recommended:  "Dilute  the  stool  with  ten  volumes  of  water,  mix 
thoroughly,  and  let  it  stand  in  a  wide-mouthed  bottle  for  twenty-four 
hours.  The  narrow  layer  between  the  thin  supernatant  liquid  and 
the  solid  sediment  contains  the  bacilli.  Remove  this  with  a  pipette, 
spread  it  on  a  cover  slip,  evaporate  slowly  to  dryness,  and  proceed  as 
with  sputum"  ("Harvard  Outlines  of  Medical  Diagnosis,"  1904,  p.  29). 

Animal  Parasites. 
The  most  important  are: 

[  I.  Amcfiba  histolytica. 

I.  Serious I        tt     ,  f  C*^)  Uncinaria  americana. 

2.  Hook-worm    <   ,,s    .      ,    ,     ^  ,      ,       , 

[  [  [b)  Anchylostoma  duodenale. 

r  3.  Bilharzia  haematobium. 

I  4.  Balantidium  coli. 

j  5.  Tape- worms;  the  beef -worm  (Taenia  saginata)  is  very  common; 

II.  Relatively       J  the  pork-worm  (Taenia  solium)  is  rare;  the  miniature  tape- 

mild,             j  worm  (Taenia  nana)   and  the  fish-worm  (Dibothriocephalus 

j  latus')    are   fairly   common.     Several   other   forms  occur  in 

j  foreign  countries. 

'(^    6.  Strongyloides  intestinalis. 

[    7.  Ascaris  lumbricoides  (round- worm) . 

8.  Oxyuris  vermicularis  (thread-worm;  pin-worm). 

9.  Trichiuris  trichiura  (whip- worm). 
10.  Trichomonas  intestinalis. 

[II.  Lamblia  intestinalis. 

'  Fish  tape-worms  may  produce  a  severe  ana?mia,  but  in  probably  the  great  majority  of 
all  cases  they  do  not  do  so. 


III.  Usually 
harmless 


Cabot — Physical  Diagnosis. 


PLATE  I. 


Fig.  I. — Trichomonas  hominis.     (Leuckart 


Fig.  2. — Balantidium  coli.     (Leuckart.)     Magnified  about  150  diameters. 


Fig.  3. — Lamblia  intestinalis.     (Leuckart.) 


THE  INTESTINE,  SPLEEN,  KIDNEY 


381 


Tape-worms,  round-worms,  pin-worms,  and  the  strongyloides  are 
to  be  recognized  in  their  adult  form  (see  Figs.  211,  212,  213,  214,  215). 
They  are  usually  noticed  by  the  patients  themselves  and  brought  to 
the  physician  for  examination.  If  the  worm  has  the  look  of  a  common 
earth-worm,  but  a  length  of  five  to  nine  inches,  it  is  safe  to  call  it  the 
"round- worm"  (Ascaris  lumbricoides) ;  if  the  worm  is  about  one-half 
an  inch  long  and  as  thick  as  a  pin,  it  is  in  all  probability  a  "  pin- worm  " 
(Oxyuris  vermicularis) . 

The  Amoeba  histolytica  is  to  be  searched  for  in  fresh  stools  passed 
into  a  warm  vessel,  after  MgS04  has  been  given.  A  bit  of  mucus  from 
such  stools  or  a  little  obtained  by 
passing  a  rectal  tube  is  put  upon  a 
warmed  slide  with  a  drop  of  water, 
covered  with   a  cover  glass,  and  ex- 


FiG.  211. — a,  Head  of  Taenia  saginata,  much  magnified;  b,  uterine  canal  of  same, 
twenty  branches  on  each  side. 


About 


amined  at  once  with  a  high-power  dry  lens.  The  organism  is  rec- 
ognized as  an  amoeba  by  the  presence  of  distinct  amoeboid  movements. 
When  dead  it  assumes  a  round  shape,  but  one  should  not  attempt  a 
positive  diagnosis  until  live  amoeboid  parasites  are  present. 


Apparently  there  is  a  harmless  variety  of  amceba  coli  to  be  obtained  from  the  stools  of 
many  normal  persons  by  purgation.  This  is  distinguished  from  the  amceba  histolytica 
by  the  following  criteria  (Vedder).  The  dysenteric  or  tissue-destroying  amoeba  is  larger, 
more  actively  motile,  has  an  easily  distinguished  refractive  ectoplasm  which  can  also  be 
made  out  in  the  pseudopods  which  are  themselves  relatively  large  and  easily  seen. 

Especially  characteristic  of  the  amoeba  histolytica  is  the  presence  of  numerous  vacuoles 
and  usually  of  ingested  red  corpuscles  which  hide  the  nucleus. 


382 


PHYSICAL  DIAGNOSIS 


The  other  parasites  are  identified,  as  a  rule,  by  the  finding  of  their 
eggs  in  the  stools.  The  technique  of  this  operation  is  described  below, 
as  exemplified  in  the  search  for  the  egg  of  uncinaria — at  present  the  egg 
most  important  for  Americans  to  recognize. 

Eggs  of  parasites  catch  the  eye  in  the  examination  of  stools,  first 
of  all,  by  the  clean-cut,  mathematical  symm^etry  of  their  oval,  when  com- 
pared with  the  irregular,  shapeless  masses  which  usually  appear  in 
slide  and  cover  preparations  from  the  faeces. 

Secondly,  the  size  of  parasitic  eggs  is 
greater  than  that  of  most  of  the  objects 
seen  in  the  faeces;  and,  thirdly,  they  are  for 
the  most  part  dark  brown,  stained  with  bile 
(the  uncinaria  is  an  exception) . 


Fig.  212. — a,  Head  of  Taenia  solium  (note  crown  of  hoolcs) ;  b,  uterine  canal  in  two  segments' 
Only  five  to  seven  branches  on  each  side. 


The  differences  between  individual  species  will  be  described  later. 
In  Plates  II.  and  III.  the  most  important  eggs  are  pictured  and 
catalogued. 

The  Uncinaria  americana  or  its  European  equivalent  {Anchylos- 
toma  duodenale)  is  recognized  most  easily  by  the  identification  of  its 
eggs  in  the  stools.  These  eggs  are  characteristic  (see  Plate  II.),  and 
"  the  only  thing  liable  to  be  confounded  with  them  is  the  ovum  of 
Ascaris  lumbricoides  stripped  of  its  heavy,  bile-stained  outer  shell 
(see  Plate  II.) ;  but  this  has  a  double  contour  and  contains  a  shapeless 
mass  of  granular  matter  not  differentiated"  (as  most  uncinaria  eggs 


Cabot — Physical  Diagnosis. 


PLATE  II. 


Distoma  buski. 


Ascaris  lumbricoides. 


Uncinaria  americana. 


Anchylostoma  duodenale. 


Trichuris  trichiura.    Dibothriocephalus  latus.  Taenia  solium. 

EGGS  OF  INTESTINAL  PARASITES. 
All  are  magnified  250  diameters. 


Taenia  saginata. 


THE  INTESTINE,  SPLEEN,  KIDNEY 


383 


are)  "into  clear  segments."^  The  greater  size  of  the  American  hook- 
worm's egg  compared  to  that  of  the  European  worm  is  shown  in  Plate 
II.  "Free  embryos  are  rarely  if  ever  found  in  intestine.  When  free 
(worm-like)  embryos  are  seen  in  the  stools,  they  are  generally  those 
of  the  Strongyloides  intestinalis"  (see  Fig.  215). 

The  ova  of  uncinaria  catch  the  eye  in  a  rapid  examination,  first, 
because  they  are  "not  generally  bile-stained,  but  clear,  whereas  those 

of  the  commonly  associated  intestinal 
parasites  are  of  a  yellow  to  deep  amber 
or  brown  color."  They  are  dis- 
tributed quite  evenly  throughout  the 
entire  fgecal  mass;  hence,  in  searching 
for  them,  the  following  method  is 
advisable : 

Technique  of  Microscopic  Exami- 
nation.— "A  bit  of  faeces  the  size  of  a 
match  head  is  removed  with  a  tooth- 
pick   and    placed    on    a    glass    slide. 


Fig.  213. — Taenia  nana  (Dwarf  Tape-worm),     a,  Hooklet;  b,  head,  greatly  enlarged;  c, 
whole  worm,  magnified  about  10  times. 


Upon  this  is  placed  a  cover  glass  and  pressed  down  so  as  to  give  a 
clear  centre  to  the  specimen.  Do  not  add  water.  Examine  with  a 
one-third  to  two-thirds  objective,  a  No.  4  ocular,  and  a  partially  closed 


^  All  the  quotations  in  this  section  are  from  the  "  Report  of  the  Commission  for  the 
Study  and  Treatment  of  Anaemia  in  Porto  Rico,"  by  Ashford,  King,  and  Igaravidez 
(December  ist,  1904),  a  study  of  5,490  cases. 


384 


PHYSICAL  DIAGNOSIS 


diaphragm.     If  too  much  light  is  admitted  the  delicate  ovum  will  be 
passed  over." 

The  following  interesting  table  (from  the  studies  of  Ashford,  King, 
and  Igaravidez  in  Porto  Rico)  shows,  roughly,  the  relative  frequency 
(in  a  tropical  climate)  of  the  common  intestinal  parasites  recognizable 


Fig.  214. 


~ri 


-Segments  of  the  Dibothriocephalus  latus  (Fish  Tape- worm), 
shaped  uterine  marking. 


Note  the  rosette- 


by  their  eggs.     In  the  examination  of  the  stools  of  5,490  cases  of  uncin- 
ariasis they  found  as  well : 

Ascaris  lumbricoides  in 1,408  (many  others  seen  but  not  noted). 

Trichuris  trichiura  in 326  (many  others  seen  but  not  noted). 


Strongyloides  intestinalis  in. 
Bilharzia  haematobium  in .  . 


Balantidium  coli  in 

Oxyuris  vermicularis  in. 

Amoeba  coli  in 

Taenia  saginata  in 

Tcenia  sohum  in 


36  (the  embryo  worms,  not  eggs). 
21  (frequently  no  careful  search 

was  made  for  this  egg) . 
14 

3 

3 


Newton  Evans  {Southern  Medical  Journal,  Nov.  191 1)  examined 
the  stools  of  1 2  2  children  in  public  institutions  of  Tennessee  and  found 
worms  in  60  children,  or  nearly  50%,  though  no  symptoms  were  present. 
The  order  of  frequency  was  as  follows : 

1.  Hook  worm  (39  cases). 

2.  Round  worm. 

3.  Whip  worm. 

4.  Dwarf  tape  worm. 

5.  Pin  worm. 

Ascaris  lumbricoides  has  usually  a  thick,  wavy  ("mammillated") 
shell;  but  this  is  not  always  seen,  and  in  its  absence  the  egg  is  dis- 


Cabot^ — Physical  Diagnosis. 


PLATE  III. 


i 


Heterophyes 
heterophyes. 


Distoma 
sinense. 


Fasciola  hepatica. 


Distoma  buski. 


Distoma 
felineum. 


Dictocoelium 
lanceolatum. 


Billiarzia         Diplogonoporus  Bilharzia 

hjematobium.  grandis.  hfcmatobium. 


Taenia 
saginata 


Dibothrio- 
cephalus  latus. 


Bilharzia 
ha-matobium. 


Ascaris 
lumbricoides. 


Oxyur's 
vermicularis. 


Paragonimus  Ta:nia  nana, 

wester  mani. 


Ascaris 
lumbricoides. 


Anchylostoma 
duodenale. 


Uncinaria 
americana 


Strongyloides 
stercoralis. 


DRAWINGS  OF  EGGS  OF  INTESTINAL  PARASITES. 
All  are  magnified  250.     (After  Looss). 


THE  INTESTINE,  SPLEEN,  KIDNEY 


385 


tinguishable  from  Uncinaria  americana  chiefly  by  the  absence  of  the 
segmentation  usually  seen  in  the  egg  of  the  latter  (see  Plate  II.,  b). 

Trichuris  trichiura  (also  called  Tricocephalus  dispar)   has  a  thick 
shell,   very  dark-stained,   and  apparently  pointed  and  perforated  at 
each  end,  instead  of  curving  evenly  over  as  the 
uncinaria  egg  does  (see  Plate  II.,  c). 

Bilharzia  eggs  are  not  at  all  uncommon  in 
the  faeces,  though  more  often  described  in  the 
urine,  in  connection  with  haematuria.  In  the 
urine  the  terminal  spine  at  one  end  is  their  most 
characteristic  feature  (see  Plate  III).  In  the 
faeces  the  spine  is  usually  at  one  side  (see 
Plate  III). 

The  other  eggs  are  briefly  described  in  the 
explanatory  text  accompanying  Plate  II. 

The  Spleen. 

Diseases  of  the  spleen  (abscess,  malignant 
disease,  cyst)  are  almost  never  recognized  during 
life.  It  is  for  evidence  of  splenic  enlargement 
as  a  factor  in  the  diagnosis  of  diseases  origi- 
nating elsewhere  that  we  investigate  the  splenic 
region  as  part  of  the  routine  of  abdominal 
examinations. 

Splenic  enlargement  is  detected  chiefly  by 
palpation.  Percussion  plays  a  minor  role  in  the 
determination  of  the  organ's  size,  and  should 
never  be  relied  on  in  the  absence  of  palpable 
evidence.  Palpation  is  easy,  provided  the  organ 
is  enlarged  sufficiently  to  project  beyond  the 
ribs  without  forced  respiration,  but  much  prac- 
tice is  needed  when  the  enlargement  is  slight,  as 
in,  for  example,  most  cases  of  typhoid  fever. 


Fig.      215. — Strongy- 
loides  stercoralis.    Mag- 
nified about  250  diame 
ters.     (After  Thayer.) 


Palpation  of  the  Spleen. 

The  co-operative  action  of  both  hands  is  as 
essential  as  in  vaginal  examination,  and  each 
hand  must  do  the  right  thing  at  the  right  moment.  The  patient 
should  be  on  his  back,  his  head  comfortably  supported  and  his  knees 
drawn  up.  The  left  hand,  placed  over  the  normal  situation  of  the 
spleen,    (a)    draws  the  whole  splenic   region    downward   and   inward 


386 


PHYSICAL  DIAGNOSIS 


toward  the  expectant  finger-tips  of  the  right  hand;  (6)  at  the  same 
time  the  left  hand  should  slide  the  skin  and  subcutaneous  tissues 
over  the  ribs  and  toward  the  right  hand  (see  Fig.  216),  so  as  to  leave 
a  loose  fold  of  skin  along  the  margin  of  the  ribs  and  give  the  palpating 
fingers  a  slack  rather  than  a  taut  covering  to  feel  through. 

The  right  hand  lies  on  the  abdominal  wall  just  below  the  margin 
of  the  ribs,  and  the  fingers  should  point  straight  up  the  path  down 
which  the  spleen  is  to  move,  i.e.,  obliquely  toward  the  left  hypo- 
chondrium.  With  the  hands  in  this  position  ask  the  patient  to 
draw  a  full  breath.     Keep  the  hands  still  and  do  not  expect  to  feel 


Fig.  216. — Position  of  the  Hands  in  Palpation  of  the  Spleen. 

anything  until  near  the  end  of  inspiration.  Then  draw  the  hands 
slightly  toward  each  other  and  dip  in  a  little  with  the  right  finger- 
tips, so  that  if  the  spleen  issues  from  beneath  the  ribs  its  edge  will 
meet  the  finger-tips  for  an  instant  and  spring  over  them  as  they 
rise  from  diving  into  the  soft  tissues  (see  Fig.  216). 

Some  physicians  have  the  patient  lie  on  the  right  side,  and,  stand- 
ing behind  him,  hook  their  fingers  over  the  ribs  in  the  left  hypo- 
chondrium.  In  this  way  we  may  be  able  to  feel  the  spleen  at  the 
end  of  a  long  inspiration,  but  I  have  seldom  found  this  position  as 
useful  as>that  described  above. 

A  hard,  fibrous  spleen  (malaria)  is  much  easier  to  feel  than  a 
soft  one  (typhoid) . 

Percussion  of  the  Spleen. 

Only  when  the  edge  of  the  spleen  has  been  felt  is  it  worth  while  to  try 
to  define  its  upper  border  by  percussion.     Normally  there  is  dulness  in 


THE  INTESTINE,  SPLEEN,  KIDNEY 


387 


the  midaxillary  line  from  the  ninth  to  the  eleventh  ribs,  corresponding 
to  that  part  of  the  spleen  that  is  most  superficial.  Its  lower  and 
posterior  borders  cannot  be  defined;  its  anterior  edge  is  approxi- 
mately in  the  midaxillary  line  (see  Fig.  59).  If  this  small  area  of  dul- 
ness  is  enlarged  upward  and  forward,  and  if  the  edge  has  been  felt 
below  the  ribs,  it  is  probable  that  the  increased  area  of  dulness  corre- 
sponds to  an  enlargement  of  the  organ. 

Causes  of  Splenic  Enlargement. 

Slight  enlargement  of  the  spleen  can  often  be  detected  in : 

1.  Rickets  and  other  debilitating  conditions  of  childhood  with  or 
without  anaemia. 

2.  Malaria. 

3.  Typhoid  fever. 


Fig.  217. — Splenic  leuasmia. 


In  other  acute  infections  slight  enlargement  can  usually  be  made 
out  post  mortem,  but  not  during  life. 

In  a  series  of  100  cases  of  marked  splenic  enlargement  studied  in 
the  Massachusetts  General  Hospital  I  found  the  following  types 


388  PHYSICAL  DIAGNOSIS 

1.  Leucaemia — 35  cases. 

2.  Hepatic  cirrhosis — 30  cases. 

3.  Malaria — 8  cases. 

4.  Hodgkin's  disease — 6  cases. 

5.  "  Splenic  Anaemia" — 4  cases. 

6.  Syphilis — 2  cases. 

7.  Polycythaemia — 2  cases. 

8.  Amyloid — i  case. 

9.  Unknown  Cause — 13  cases. 

Rarer  causes  are  abscess,  tuberculosis,  malignant  disease,  perni- 
cious anaemia,  hydatid,  and  Leishman-Donovan  disease. 

Differences  Between  a  Large  Spleen  and  Tumors  (of  the  kidney  or 
other  organs). — A  large  spleen  is  easily  recognized  after  a  little 
practice.  As  it  enlarges  it  keeps  its  shape  and  advances  obliquely 
across  the  belly  toward  the  navel  or  (in  marked  cases)  beyond  it. 

It  is  always  hard  and  smooth  of  surface,  although  the  edge  near- 
est the  epigastrium  shows  one  or  more  notches  which  are  very  char- 
acteristic. The  edge  is  sharp,  never  rounded,  and  the  whole  organ 
is  very  superficial,  being  covered  only  by  the  belly  walls,  so  that  if 
we  inflate  the  colon  (by  forcing  air  into  the  rectum  with  a  Davidson 
syringe),  it  passes  behind  the  spleen  and  does  not  obliterate  its  dulness. 

Tumors  of  the  kidney  fill  out  the  flank,  and  an  impulse  can  be 
transmitted  to  the  lumbar  region  by  bimanual  palpation.  They 
have  no  sharp  edge  or  notches,  are  often  irregular  of  surface,  and 
not  so  superficial.  The  inflated  colon  passes  in  front  of  a  tumor  of 
the  kidney  and  obliterates  the  dulness  due  to  it. 

All  these  differences  hold  for  any  other  tumors  likely  to  be  con- 
fused with  an  enlarged  spleen. 

Differential  Diagnosis  of  the    Various  Causes  of  Splenic 
Enlargement. 

In  children  splenic  enlargement  without  fever  or  leukaemic  blood 
changes  is  to  be  classed  as  a  manifestation  of  general  debility.  It 
has  no  special  connection  with  any  type  of  anaemia,  though  anaemia 
is  often  seen  with  it. 

In  typhoid  the  fever  with  the  Widal  reaction  and  blood  culture  are 
generally  sufficient  to  make  clear  the  cause  of  the  splenic  enlargement; 
in  active  malaria  the  blood  parasites  are  always  demonstrable,  and  in 
chronic  cases  the  history  and  the  locality  are  significant. 

Hepatic  cirrhosis  (and  Banti's  disease)  should  show  evidences  of 
portal  stasis  (ascites,  jaundice,  haematemesis) . 


THE  INTESTINE,  SPLEEN,  KIDNEY  389 

Splenic  anxmia  means  simply  an  anaemia  of  unknown  origin 
associated  with  an  enlarged  spleen. 

Leukcemic  enlargement  of  the  spleen  is  easily  recognized  by  the 
characteristic  blood  picture. 

Hodgkin's  disease  shows  glandular  enlargements  in  the  neck, 
axillae,  and  groins,  with  normal  blood.  Histological  examination 
of  an  excised  gland  is  necessary  for  diagnosis. 

Amyloid  can  be  suspected  (never  positively  diagnosed)  as  the 
cause  of  an  enlarged  spleen,  if  there  is  a  history  of  syphilis  or  chronic 
suppuration  (hip  abscess,  phthisis,  etc.). 

Diseases  of   the  Kidney. 

Incidence  of  Renal  Disease  (Massachusetts  General  Hospital,  1 8  70-1 905). 

Acute  nephritis 200 

Chronic  glomerulo-nephritis 417 

Chronic  interstitial  nephritis 250' 

Amyloid  nephritis 9 

Floating  kidney 227 

Stone  in  the  kidney 145 

Malignant  disease 42 

Tuberculous  kidney 41 

Pyonephrosis  and  abscess 54^ 

Perinephritic  abscess '  35 

Hydronephrosis 19 

C3'stic  kidneys 10 

Total 1 ,449 

We  get  evidence  of  diseases  of  the  kidney  in  four  ways : 

1.  By  external  examination  of  the  region  of  the  kidney. 

2.  By  examination  of  the  urine. 

3.  By  cystoscopy  and  the  ureteral  catheter. 

4.  By  study  of  the  constitutional  symptoms — fever,  leucocytosis, 
anaemia,  uraemia,  dropsy,  blood  pressure  and  cardiac  hypertrophy. 

Local  examination  acquaints  us  with  the  presence  of  tenderness 
and  tumor. 

(a)  Tenderness  is  often  present  in  abscess  of  the  kidney  (tuber- 
culous or  non-tuberculous)  and  in  perinephritic  abscess,  less  often  in 
connection  with  nephrolithiasis,  occasionally  in  hydronephrosis  and 
malignant  disease.     A  floating  kidney  may  have  an  exquisite  and 

'  Seven  hundred  and  seventy-five  other  cases  of  "nephritis"  not  further  specified. 
^  Including  acute  hsematogenous  cases  and  pyelitis. 


390  PHYSICAL  DIAGNOSIS 

peculiar    sensitiveness     to     pressure,     which    differs    from    ordinary- 
tenderness. 

(b)  Tumor  in  the  kidney  region  may  occur  in  abscess  in  or  around 
the  kidney  (including  tuberculosis  of  the  kidney  and  pyonephrosis), 
malignant  disease,  hydronephrosis,  and  cystic  kidney.  The  latter 
members  of  this  list  afford  examples  of  the  largest  tumors  associated 
with  the  kidney. 

Characteristics  Common  to  Most  Tumors  of  the  Kidney. 

Renal  tumors  are  best  felt  bimanually,  one  hand  in  the  hypo- 
chondrium  and  the  other  in  the  region  of  the  kidney  behind,  with 
the  patient  in  the  recumbent  position.  In  this  way  the  tumor  may 
often  be  grasped  and  an  impulse  transmitted  from  hand  to  hand. 
It  is  usually  round  and  smooth,  often  very  hard,  less  often  fluctu- 
ating. It  descends  slightly  with  inspiration.  If  the  colon  is  in- 
flated by  forcing  air  into  the  rectum  with  a  Davidson  syringe,  res- 
onance appears  in  front  of  the  tumor;  this  serves  to  distinguish  it 
from  tumors  of  the  spleen  which  are  pushed  forward  by  the  inflated 
colon  as  it  passes  behind  them.  Tumors  of  the  kidney  never  pre- 
sent a  thin  and  sharp  edge,  like  that  of  the  spleen.  Occasionally 
they  are  irregular  and  nodulated — a  condition  almost  never  found 
in  the  spleen.  It  must  be  remembered  that  an  enlarged  kidney  may 
be  the  sound  kidney  hypertrophied  in  compensation  for  disease  on 
the  other  side. 

(a)  Malignant  disease  of  the  kidney,  sarcoma,  or  hypernephroma, 
makes  up  with  cystic  kidney  the  great  bulk  of  the  large  abdominal 
tumors  occurring  in  childhood,  but  is  also  not  uncommon  in  adults. 
The  characteristics  of  the  tumor  are  those  already  described,  except 
that  in  advanced  stages  the  tumor  pushes  forward  from  its  position  in 
the  loin  until  it  may  reach  the  umbilicus  or  even  fill  the  abdomen. 
Nodular  irregularities  can  usually  be  felt.  There  is  usually  pain, 
hsematuria,  emaciation,  and  anaemia,  sometimes  leucocytosis,  but 
small  tumors  at  some  distance  from  the  renal  pelvis  are  symptomless 
and  unrecognizable.  Metastases — especially  bone  metastases — are 
often  the  first  evidence  of  the  disease. 

(6)  Hydronephrosis  and  cystic  kidney  may  be  indistinguishable 
from  each  other  unless  the  hydronephrosis  is  intermittent  and  dis- 
appears with  a  great  gush  of  urine,  or  unless  the  cystic  kidney  is 
bilateral — as,  indeed,  is  usually  the  case.  In  both  diseases  a  smooth, 
round  tumor  forms  in  the  loin  and  hypochondrium,  usually  without 


THE  INTESTINE,  SPLEEN,  KIDNEY 


391 


much  constitutional  disturbance  and  very  frequently  with  a  urine 
like  that  of  chronic  interstitial  nephritis  (see  below)  (see  Fig.  218). 
Pain  and  tenderness  are  slight.  The  tumor  may  be  astonishingly 
hard  and  often  gives  no  sign  of  fluctuation.  With  cystic  kidney  it 
may  be  coarsely  lobulated.  Like  other  tumors  of  the  kidney  it  de- 
scends slightly  on  inspiration.  Cystic  kidneys  are  often  congenital, 
but  usually  produce  no  symptoms  until  they  have  attained  a  consid- 
erable size,  and  hence  are  often  overlooked  or  discovered  accident- 
ally. In  hydronephrosis  the  diag- 
nosis may  be  assisted  by  etiological 
hints,  such  as  an  abnormal  degree  of 
mobility  of  the  kidney  on  the  affected 
side,  a  history  of  renal  colic  with  or 
without  hasmaturia,  or  a  prostatic 
obstruction.  Comparatively  slight 
degrees  of  dilatation  or  distortion  of 
the  renal  pelvis  and  their  relation  to 
kinking  of  the  ureter  may  be  made 
out  by  the  use  of  coUargol-radio- 
graphic  plates.  Braasch,  from  the 
Mayos'  clinic,  considers  this  method 
of  practical  value  in  the  diagnosis  of 
hydronephrosis,  pyonephrosis,  pyelitis 
(which  shows  dilatation  of  the  pelvis), 
renal  tuberculosis  and  tumors,  cystic 
kidney,  hydro-ureter  and  ureteral  ob- 
struction, and  for  other  purposes.  I 
have  no  experience  with  this  method,  but  it  sounds  promising. 

(c)  Perinepkritic  abscess  usually  works  its  way  to  the  surface  in  the 
back,  between  the  crest  of  the  ilium  and  the  twelfth  rib.  This  was  the 
situation  of  the  external  tumor  in  25  out  of  35  cases  recorded  at  the 
Massachusetts  General  Hospital.  A  tender  swelling  appears  at  the 
point  just  described,  sometimes  with  redness  and  heat,  and  almost 
always  with  fever,  chills,  leucocytosis,  and  some  emaciation.  The 
urine  may  show  nothing  abnormal  or  may  show  the  evidence  of  cys- 
titis, of  concomitant  nephritis,  or,  rarely,  of  an  abscess  within  the 
kidney  itself.  Perinephritic  abscess  often  remains  latent  for  weeks 
or  months,  and  the  amount  of  pus  accumulated  may  be  a  quart  or 
more. 

(d)  Abscess  of  the  kidney,  including  tuberculous,  suppurating  kid- 
neys and  pyonephrosis,  usually  produces  a  smooth,  round  tumor  in 


Fig.  218. — Left  Hydronephrosis. 


392  PHYSICAL  DIAGNOSIS 

the  hypochondrium  and  loin.     It  has  the  characteristics  common  to 
most  renal  tumors  (see  last  page),  but  is  usually  distinguishable  by: 

1.  The  etiology  (cystitis,  stone  in  the  kidney,  tuberculosis,  pyae- 
mia).    In  acute  cases,  however,  there  is  often  no  discoverable  cause. 

2.  The  presence  of  renal  pyuria  (see  below,  page  395). 

3.  The  presence  of  fever,  leucocytosis,  and  the  usual  constitu- 
tional signs  of  an  infectious  process.  Persistent  urinary  frequency,  es- 
pecially nocturnal,  in  a  young  adult  suggests  renal  tuberculosis. 
Bladder  irritation  is  usually  the  first  symptom  of  renal  tuberculosis, 
even  though  the  bladder  itself  is  apparently  normal. 

(e)  Floating  Kidney;  Displaced  and  Movable  Kidney. — The  tip 
of  the  right  kidney  is  palpable  in  most  thin  persons  with  loose  belly 
walls.  If  the  whole  organ  is  palpable  but  not  movable,  we  speak 
of  it  as  displaced.  If  the  range  of  mobility  is  relatively  great  we 
call  it  floating;  if  relatively  slight  we  call  it  movable.  With  bimanual 
palpation  (as  described  above)  we  exert  pressure  just  at  the  end  of 
a  deep  inspiration  and  maintain  it.  During  expiration  something 
smooth  and  round  may  then  be  felt  to  slip  upward  between  our 
hands  toward  the  ribs.  If  the  kidney  "hides"  behind  the  ribs,  have 
the  patient  sit  up,  cough,  and  breathe  deeply;  then  repeat  the  bimanual 
palpation  as  he  lies  on  his  back.  Very  movable  or  floating  kidneys 
may  be  found  far  from  their  normal  home,  and  are  then  recognized  by : 
I.  Their  size,  shape,  and  slippery  feel.  2.  The  sickening  pain  pro- 
duced by  pressure.     3.  The  possibility  of  replacing  them. 

Renal  Colic  and  Other  Renal  Pain. 

Typical  renal  colic  is  paroxysmal,  like  all  colics;  that  is,  an  attack 
begins  suddenly,  ends  suddenly,  and  lasts  but  a  few  hours  or  less. 
The  pain  usually  begins  in  the  back,  over  the  kidney,  and  follows 
the  course  of  the  ureter  to  the  groin.  During  an  attack  the  testicle 
on  the  affected  side  may  be  tender  and  drawn  up  tightly  by  contrac- 
tion of  the  cremaster. 

When  associated  with  hematuria  or  pyuria,  with  or  without  sud- 
den stoppage  of  water  during  an  attack  and  without  any  general  or 
constitutional  symptoms  between  attacks,  renal  colic  is  strongly  sug- 
gestive of  stone  in  the  pelvis  of  the  kidney;  but  similar  attacks  may 
occur  with  other  surgical  diseases  of  the  kidney,  with  tuberculosis, 
neoplasm,  with  kinking  of  the  ureter,  and  very  often  without  any 
cause  discoverable  at  operation. 

From  biliary  colic  it  may  be  distinguished  by  the   (a)   different 


THE  INTESTINE,  SPLEEN,  KIDNEY  393 

situation  of  the  pain,  (b)  by  the  presence  of  blood  or  pus  in  the  urine, 
and  (c)  the  absence  of  jaundice  in  this  or  a  former  attack. 

In  intestinal  colic  the  pain  shifts  its  position  frequently  and  is 
associated  wi,th  noises  produced  by  wind  in  the  bowels,  or  with  diar- 
rhoea or  constipation. 

Renal  pain,  not  colic,  occurs  in  almost  any  disease  of  the  kidney 
except  nephritis,  and  is  characterized  by  its  situation  over  the  ana- 
tomical seat  of  the  kidney  and  by  the  lack  of  any  connection  with 
muscular  movements  (lumbago),  with  spinal  movements  (hypertro- 
phic arthritis),  or  with  the  sacro-iliac  joint. 

I  have  now  described  what  seems  to  me  most  important  in  the 
local  external  examination  for  kidney  disease,  and  have  mentioned, 
along  with  the  different  lesions  producing  tumor,  the  general  con- 
stitutional manifestations  which  are  of  assistance  in  diagnosis.  Aside 
from  the  local  and  the  constitiitional  evidence  of  renal  disease  (high 
blood  pressure  and  enlarged  heart),  we  have  only  the  evidence  afforded 
by  the  urine,  to  which  I  now  pass  on. 

Examination  of  the   Urine. 

The  urine  as  passed  per  urethram  is  a  resultant  and  reflects  the 
influence  of  many  different  organs  and  surfaces.  Thus  disturb- 
ances of  metabolism,  such  as  diabetes,  intoxications  (lead,  arsenic), 
diseases  of  the  heart,  liver,  and  intestine,  febrile  conditions,  infec- 
tive or  malignant  disease  of  any  part  of  the  urinary  tract  (kidney, 
ureter,  bladder,  or  urethra) ,  as  well  as  the  different  types  of  nephritis, 
all  affect  the  urine,  though  hardly  any  of  them  produce  pathognomonic 
changes  in  it.  In  this  section  I  shall  consider  the  urine  as  a  piece  of 
evidence  in  the  diagnosis  of  kidney  disease,  and  only  in  contrast  with 
this  will  its  characteristics  in  extrarenal  troubles  be  mentioned  briefly. 

The  most  essential  features  of  the  urine  in  the  diagnosis  of  kid- 
ney disease  are : 

1.  The  amount  passed  in  twenty-four  hours,  measuring  sepa- 
rately the  portions  passed  at  night  (8  p.m.  to  8  a.m.)  and  in  the  day- 
time (8  a.m.  to  8  p.m.). 

2.  The  specific  gravity. 

3.  The  looks  (optical  properties). 

4.  The  reaction  to  litmus. 

5.  The  presence  of  blood,  pus,  or  tubercle  bacilli. 

6.  The  presence  or  absence  of  albumin  and  sugar. 

Much  less  important  than  these  is  the  presence  or  absence  of  casts, 
cells,  crystals,  etc. 


394  PHYSICAL  DIAGNOSIS 

The  Amount  and  Weight  of  the   Urine. 

The  twenty-four-hour  amount  concerns  us  chiefly  in  diabetes  and 
the  different  types  of  nephritis. 

Polyuria  occurs  in  health  after  the  ingestion  of  large  quantities 
of  water,  and  sometimes  in  conditions  of  nervous  strain.  In  dis- 
ease it  characterizes  both  forms  of  diabetes,  cirrhotic  kidney  (pri- 
mary, secondary,  or  arterio-sclerotic) ,  and  is  seen  during  the  con- 
valescence from  acute  nephritis  and  from  various  infectious  diseases. 
It  also  occurs  in  the  early  stages  of  renal  tuberculosis  or  when  con- 
tinuous drainage  (catheter)  is  established  in  cases  of  prostatic  obstruc- 
tion. In  diabetes  of  either  form  several  quarts  or  even  gallons  may  be 
passed.  In  cirrhotic  kidney  the  increase  of  urine  occurs  very  largely 
at  night,  so  that  the  amount  may  be  double  that  passed  in  the  day- 
time, just  reversing  the  conditions  of  health. 

Oliguria  or  scanty  urine  occurs  in  health  when  the  amount  of 
water  ingested  is  small  or  when  water  is  passed  out  of  the  body 
abundantly  through  the  skin  or  by  the  bowels  (diarrhoea).  In  dis- 
ease oliguria  or  absolute  suppression  of  urine  {anuria)  occurs  at  the 
beginning  of  acute  nephritis  and  as  a  result  of  occlusion  of  one  or 
both  ureters  by  stone  or  malignant  disease.^  Remarkable  examples 
of  anuria  also  occur  in  hysteria.  Infectious  fevers  and  cachectic  states 
often  diminish  the  secretion  of  the  urine  by  one-half  or  more. 

The  specific  gravity  is  usually  low  with  polyuria  and  high  with 
oliguria,  but  in  diabetes  mellitus  the  presence  of  the  sugar  gives  us 
polyuria  with  high  specific  gravity. 

Total  Urinary  Solids. — By  multiplying  the  last  two  figures  of 
the  specific  gravity  by  the  number  of  ounces  of  urine  passed  in  twenty- 
four  hours  and  the  product  by  i.i,  we  get  a  figure  representing  the 
total  urinary  solids  in  grains,  with  accuracy  sufficient  for  clinical 
diagnosis.  Thus  if  30  ounces  of  urine  are  passed  in  24  hours  and 
the  gravity  is  1.020,  then  20X30X  i.i  =660  grains.  The  significance 
of  this  figure  will  be  discussed  later  (see  page  400). 

Optical  Properties. 

Color. — Dilute  urines  (polyuria)  are  generally  pale,  and  concen- 
trated urines  (oliguria)  high  in  color.  A  dark  or  brownish  tint  in 
the  urine  is  generally  produced  by  bile,  by  blood  pigment,  or  as  a 

1  It  is  a  remarkable  but  well-attested  fact  that  when  one  ureter  is  suddenly  blocked 
both  kidneys  may  stop  secreting  for  the  time.  Yet  when  one  kidney  is  gradually  destroyed 
as  in  tuberculosis,  the  other  hypertrophies  so  as  to  assume  the  function  of  both. 


THE  INTESTINE,  SPLEEN,  KIDNEY  395 

result  of  certain  drugs — carbolic  acid,  coal-tar  preparations,  and 
salol.  If  the  color  is  due  to  bile,  a  bright  canary  yellow  appears  in 
the  foam  after  shaking  up  a  little  of  the  urine  in  a  test  tube.  No 
other  tests  for  bile  are  necessary.  Urines  darkened  by  blood  pig- 
ment show  abundant  blood  corpuscles  in  the  sediment;'  when  the 
color  is  due  to  drugs  we  can  usually  learn  this  fact  from  the  history. 

Turbidity  in  alkaline  urine  is  usually  due  to  the  presence  of  bac- 
teria. In  acid  urine  it  is  produced  in  a  great  majority  of  cases  by 
amorphous  urates,  and  disappears  on  heating  the  urine,  while  the 
turbidity  due  to  bacteria  is  unaffected  by  heat.  Normal  urine  may 
be  turbid  and  alkaline,  owing  to  the  presence  of  insoluble  carbon- 
ates and  phosphates,  but  clears  on  the  addition  of  acetic  acid. 
Hence  turbidity,  not  removed  by  heat  or  acetic  acid,  is  almost  always 
due  to  bacteria  and  pus,  i.e.,  to  cystitis,  pyelonephritis,  or  both. 

Shreds  seen  floating  in  the  urine  and  found  to  be  composed  mostly 
of  pus  are  presumptive  evidence  of  urethritis,  and  practically  always 
of  gonorrhoea. 

The  gross  sediment  as  seen  by  the  naked  eye  amounts  in  health 
to  nothing  more  than  a  slight  cloud,  which  settles  in  the  lower  part 
of  the  vessel  containing  the  urine.  This  cloud  is  somewhat  denser 
in  women  than  in  men,  owing  to  the  presence  of  vaginal  detritus. 
When  the  gross  sediment  amounts  to  anything  more  than  this,  it  is 
almost  invariably  made  up  of  (a)  pus,  (b)  blood,  or  (c)  urates.  The 
latter  are  dissolved  on  heating.  Pus  has  usually  its  ordinary  yellow 
color  and  general  appearance.  Blood  may  be  somewhat  lighter  or 
somewhat  darker  than  under  ordinary  conditions,  but  is  usually 
recognized  without  difficulty. 

Significance  of  these  Sediments. — A  urate  sediment  means 
nothing  more  than  a  concentrated  urine  standing  in  a  cold  room. 
In  the  winter-time  patients  often  bring  us,  in  great  alarm,  a  bottle 
of  milky  or  fawn-colored  and  turbid  urine,  which  is  not  in  any  way 
abnormal.  The  urates  have  been  precipitated  over  night  by  the  low 
temperature  of  the  bedroom. 

Pyuria,  or  gross  pus  in  the  urine,  is  oftenest  seen  in  cystitis  and 
less  often  in  pyelonephritis  and  renal  suppurations,  tuberculous  or 
pyogenic.  The  pus  occurring  in  gonorrheal  urethritis  is  usually  much 
less  in  quantity  than  that  coming  from  the  bladder  or  kidney,  and  can 
be  distinguished  by  the  local  signs  of  gonorrhoea.  Leucorrhoeal  pus 
can  be  excluded  by  withdrawing  the  urine  by  catheter.     The  rupture 

^  Except  in  some  cases  of  haemoglobinuria. 


396  PHYSICAL  DIAGNOSIS 

into  the  urinary  passages  of  an  abscess  from  the  prostate  or  any  part 
of  the  pelvis  may  produce  a  profuse  but  transient  pyuria. 

After  excluding  gonorrhoea,  leucorrhoea,  and  abscess,  which  can 
usually  be  done  with  the  help  of  a  good  history  and  a  catheter,  we 
have  left  cystitis  and  renal  suppurations,  which  it  is  very  important 
and  sometimes  difficult  to  differentiate.  In  both  we  have  the  fre- 
quent and  painful  passage  of  small  quantities  of  a  urine  which  is  in 
no  way  remarkable  except  in  containing  large  amounts  of  pus  and 
bacteria.  Cystoscopy  is  often  essential.  In  the  vast  majority  of 
cases  "cystitis"  is  secondary  to  some  other  disease  above  or  below 
the  bladder — e.g.,  to  prostatic  obstruction,  renal  tuberculosis,  etc. 

In  many  cases  the  differentiation  may  be  accomplished  as  fol- 
lows: Have  the  patient  save  for  twenty-four  hours  the  urine  voided 
at  each  passage  in  a  separate  bottle  (all  of  the  bottles  being  of  uni- 
form size) ,  and  mark  each  bottle  with  the  hour  at  which  it  was  filled. 
Then  arrange  the  specimens  in  a  row,  beginning  with  that  passed 
earliest  and  ending  with  that  passed  last.  Now  if  the  case  is  one 
of  cystitis  without  involvement  of  the  kidney,  the  amount  of  pus 
that  settles  is  practically  the  same  in  each  bottle  (allowing  for  differ- 
ences in  the  amount  of  urine  in  the  different  bottles).  But  if  the 
pus  comes  from  the  kidney,  it  is  almost  always  discharged  inter- 
mittently, and  hence  some  of  the  bottles  will  be  almost  free  from 
sediment,  while  in  a  group  of  the  others  the  amount  of  pus  increases 
as  we  pass  along  the  line,  reaches  a  maximum  in  one  or  two  bottles, 
and  decreases  again  in  those  representing  the  later  acts  of  micturition. 

Pus  from  the  bladder  is  generally  alkaline,  although  in  tubercu- 
losis it  may  be  acid;  pus  from  the  kidney  is  generally  acid.  When 
both  organs  are  involved,  as  is  frequently  the  case,  we  have  a  mixture 
of  the  characteristics  of  both  types  of  pyuria,  and  cystoscopic  ex- 
amination with  or  without  catheterization  of  the  ureters  is  usually 
necessary. 

In  renal  pyuria  we  often  have  local  signs  in  the  renal  region 
(tumor  and  tenderness),  a  history  of  renal  colic,  and  decided  con- 
stitutional symptoms. 

In  vesical  pyuria  we  have  vesical  pain,  often  tenesmus,  no  renal 
pain  or  tumor,  and  usually  slighter  constitutional  symptoms.  The 
amount  of  squamous  epithelium  (see  below)  is  sometimes  larger  in 
cystitis  than  in  renal  suppurations,  but  no  reliable  inferences  can  be 
drawn  from  the  size  or  shape  of  the  cells. 

To  determine  whether  pus  from  the  bladder  or  the  kidney  is  tuber- 
culous or  non-tuberculous  in  origin,  we  usually  inject  the  sediment 


THE  INTESTINE,  SPLEEN,  KIDNEY  397 

into  a  guinea-pig,  which  develops  tuberculosis  or  not  according 
to  the  nature  of  the  pus  injected.  This  method  is  much  more  reliable 
than  the  bacteriological  examination  of  the  sediment,  for  besides 
the  tubercle  bacillus  other  bacilli  which  retain  fuchsin  and  resist 
decolorization  by  strong  mineral  acid  and  by  alcohol  occasionally 
occur  in  the  urine. 

HcFmaturia. — In  searching  for  the  source  of  the  blood  we  must 
be  sure  to  exclude  the  female  genital  organs.  Menstrual  blood  and 
uterine  bleeding  from  various  other  causes  often  contaminate  the 
urine,  and  must  be  excluded  by  using  a  catheter. 

The  causes  of  true  haematuria,  arranged  approximately  in  the 
order  of  frequency,  are : 

1.  Acute  nephritis  and  acute  hemorrhage  in  chronic  nephritis. 

2.  Stone  in  the  kidney  (less  often  vesical  stone). 

3.  Tumors  of  the  kidney  or  bladder. 

4.  Tuberculosis  of  the  kidney  or  bladder. 

5.  Early  cystitis. 

Less  common  causes  are:  floating  kidney,  hydronephrosis  and 
cystic  kidneys,  animal  parasites  in  the  urinary  passages,  poisons 
(turpentine,  carbolic  acid,  cantharides) ,  hemorrhagic  diseases  (pur- 
pura, scurvy,  leukaemia),  trauma  and  renal  infarction.  In  nearly 
one-fourth  of  all  cases  no  cause  can  he  found. 

In  cystitis  there  are  bladder  symptoms — pain,  tenesmus,  fre- 
quent and  painful  micturition.  The  blood  is  mixed  with  pus  and 
epithelium,  and  is  especially  abundant  in  the  urine  passed  near  the 
end  of  the  act  of  micturition.  If  the  bladder  is  irrigated  it  is  hard 
to  get  the  wash-water  clear.  Cystoscopy  demonstrates  or  upsets 
the  diagnosis  and  also  serves  to  show  some  other  disease  to  which  the 
cystitis  is  secondary.      Distrust  all  diagnoses  of  "primary  cystitis." 

In  renal  stone  there  are  no  bladder  symptoms  to  speak  of,  the 
blood  is  pure  and  thoroughly  mixed  with  the  urine,  and  if  the  bladder 
is  washed  out  the  final  wash-water  is  clear.  There  is  often  renal 
colic  (see  p.  392)  and  sometimes  the  passage  of  stones  or  gravel  by 
urethra.     X-ray  evidence  is  usually  conclusive. 

In  acute  nephritis  the  blood  is  rarely  fresh,  generally  dark  choco- 
late in  color.  The  twenty-four-hour  amount  of  urine  is  small,  and 
albumin  and  casts  (see  below)  are  abundant.  General  oedema  is 
common.  Local  symptoms  in  the  kidney  or  bladder  are  absent. 
Most  cases  of  "acute  nephritis"  in  adults  turn  out,  on  careful  study,  to 
represent  acute  exacerbations  of  chronic  nephritis. 

In  renal  tumor  and  especially  in  renal  tuberculosis  we  have  often 


398  PHYSICAL  DIAGNOSIS 

pyuria  and  the  local  and  constitutional  evidences  above  described 
(page  390),  with  marked  and  early  bladder  symptoms  (even  when  the 
bladder  is  not  diseased) . 

Tumors  of  the  bladder  need  cystoscopy  for  diagnosis. 

In  the  diagnosis  of  the  rarer  forms  of  hsematuria  we  rely  chiefly 
on  the  history  (trauma,  poisons  ingested)  and  on  the  evidences 
afforded  by  cystoscopy  and  general  physical  examination. 

Chemical  Examination  of  the  Urine. 
/.   The  Reaction  of  the   Urine. 

The  reaction  of  normal  urine  is  acid  to  litmus,  except  temporarily 
after  large  meals.  Its  acidity  becomes  excessive  in  fevers  or  occasionally 
without  any  known  cause. 

Alkaline  urine  has  generally  an  ammoniacal  odor  and  suggests 
cystitis.  As  a  result  of  decomposition  and  bacterial  fermentation  all 
urine  becomes  alkaline  (ammoniacal)  on  standing  exposed  to  air.^ 
Occasionally  we  find  urine  alkaline  from  fixed  alkali  and  without 
known  cause. 

The  vahie  of  the  litmus  test  is  chiefly  as  prima-facie  evidence  of 
stasis  in  the  bladder  and  cystitis.  Occasionally  tuberculous  cystitis 
and  the  first  stages  of  any  variety  of  cystitis  are  associated  with 
acid  urine,  but  in  most  cases  lasting  over  a  week  ammoniacal  fer- 
mentation and  alkalinity  appear. 

IL  Albuminuria  and  the  Tests  for  It. 

Serum  albumin  is  the  only  variety  of  clinical  importance,  and 
for  this  but  two  tests  are  necessary:  (i)  Nitric-acid  test;  (2)  test 
by  boiling. 

The  nitric-acid  test  is  best  performed  in  a  small  wineglass.  After 
filling  this  half  full  of  urine,  insert  a  small  glass  funnel  to  the  bottom 
of  the  urine  and  gently  pour  in  concentrated  nitric  acid.  If  albumin 
is  present,  a  white  ring  forms  at  the  junction  of  the  acid  with  the 
urine,  either  immediately  or  in  the  course  of  ten  minutes.  If  care- 
fully performed  this  test  is  delicate  enough  for  all  clinical  purposes, 
but  since  some  of  the  albumoses  give  a  similar  precipitate,  the  boiling 
test  should  be  used  as  a  control  whenever  a  positive   reaction    is 

'  Simultaneously  a  dark-brown  color  rarely  appears:  alkaptonuria,  a  fact  at  present  of 
no  clinical  significance  except  that  such  urines  reduce  Fehling's  solution  and  may  be  mis- 
takenly supposed  to  contain  sugar. 


THE  INTESTINE,  SPLEEN,  KIDNEY 


399 


obtained  with  nitric  acid.  None  of  the  other  rings,  observable  above 
or  below  but  not  at  the  junction  of  the  acid  with  the  urine,  is  of  any 
clinical  importance. 

The  Boiling  Test. — To  half  a  test  tube  full  of  urine  add  three  or 
four  drops  of  dilute  acetic  acid,  and  boil  the  upper  three-quarter 
inch  of  the  urine.  If  albumin  is  present  a  white  cloud  appears.  If 
the  Bence-Jones  body  is  present  a  white  cloud  appears 
on  heating,  disappears  on  boiling,  and  reappears  on 
cooling.  In  performing  this  test  the  addition  of  acetic 
acid  as  above  described  is  absolutely  necessary  to 
prevent  error. 

For  the  detection  of  albumin  no  other  tests  are 
needed.  For  its  approximate  quantitative  estimation, 
Esbach's  method  is  the  best. 

Esbach's  Method. — A  special  tube  (see  Fig.  219)  is 
employed.  Urine  is  poured  in  up  to  the  mark  "U," 
and  then  Esbach's  reagent^  up  to  the  mark  "R."  The 
tube  is  then  corked,  inverted  about  half  a  dozen  times, 
and  set  aside  for  twenty-four  hours.  A  precipitate 
falls  and  the  amount  per  mille  is  then  read  off  on  the 
scale  etched  upon  the  tube.  If  the  urine  is  not  acid 
it  must  be  made  so  with  dilute  acetic  acid,  and  unless 
its  specific  gravity  is  already  very  low  it  should  be 
diluted  once  or  twice  with  water  so  as  to  bring  the 
gravity  below  1.008.  After  such  a  dilution  we  must,  of 
course,  multiply  the  result  obtained  by  a  figure  cor- 
responding to  the  dilution.  The  method  is  not  accurate, 
but  is  probably  accurate  enough  for  practical  purposes, 
if  all  tests  are  made  at  approximately  the  same  temper- 
ature. 


///.   Significance  of  Albuminuria.  Fig.  219. — 

Esbach's  Albu- 
It    is    important   to  realize  that  albuminuria   very    menometer. 

often  occurs  without  nephritis  and  that  nephritis  occa- 
sionally  occurs   without    albuminuria.     Among  the  more  important 
types  not  due  to  kidney  disease  are  the  following:   (i)  Febrile  albu- 
minuria;  (2)   albuminuria  from  renal  stasis;  (3)  albuminuria  due  to 
pus,  blood,  bile,  or  sugar  in  the  urine;   (4)  toxic  albuminuria. 

Besides  these,  there  are  a  good  many  cases  of  albuminuria  occur- 
ring in  diseases  of  the  blood,  after  violent  exertion,   after  epileptic 
^  Esbach's  reagent:  Picric  acid,  10  gm.;  citric  acid,  20  gm.;  distilled  water,  1,000  c.c. 


400  PHYSICAL  DIAGNOSIS 

attacks,  and  without  any  known  cause.  Many  of  the  latter  group 
occur  only  in  the  daytime  when  the  patient  is  in  an  upright  position, 
and  are  absent  as  long  as  the  patient  lies  down  {orthostatic  albuminuria) ; 
others  occur  intermittently  and  sometimes  at  regular  intervals  {cyclic 
albuminuria).  Most  of  these  cases  appear  at  adolescence  and  pass 
off  without  any  signs  of  nephritis  ever  developing. 

Exclude  fever,  circulatory  disturbance,  anaemia,  poisons — such  as 
cantharides,  turpentine,  carbolic  acid,  and  arsenic — and  deposits  of 
blood  or  pus  in  the  urine,  before  deciding  that  a  case  of  albuminuria 
is  due  to  nephritis.  In  general,  however,  it  is  a  good  rule  not  to 
attribute  albuminuria  to  nephritis  unless  there  is  other  and  more 
convincing  evidence  in  the  physical  characteristics  of  the  urine  and 
in  the  other  organs  of  the  patient.  If  the  24-hour  amount  and  the 
gravity  are  approximately  normal,  and  if  there  is  no  oedema,  no 
increased  blood  pressure,  no  cardiac  hypertrophy,  no  ursemic  mani- 
festations, and  nothing  alarming  in  the  sediment  of  the  urine,  we 
should  not  diagnose  nephritis.  I  shall  discuss  this  point  further  in 
the  section  on  the  examination  of  the  sediment  (see  page  403).  It  will 
be  noted  that  practically  all  the  types  of  albuminuria  not  due  to  neph- 
ritis are  transient,  while,  with  the  exception  of  certain  stages  of 
chronic  interstitial  nephritis,  the  albuminuria  of  nephritis  is  as  per- 
manent as  the  nephritis  itself.  On  the  other  hand  many  cases  of 
nephritis (  so  proved  by  autopsy)  show  no  albuminuria  for  long  periods. 
They  are  then  to  be  recognized  by  the  evidence  and  the  result  of  high 
blood  pressure. 

IV.   Significance  of  Albumosuria. 

The  Bence-Jones  body  is  very  constantly  present  in  the  urine  of 
cases  of  multiple  myeloma.  So  far  it  has  not  been  reported  in  any 
other  disease.     Deuteroalbumoses  have  no  clinical  significance. 

V .   Glucosuria  and  Its  Significance. 

For  glucose  in  the  urine  we  need  but  one  qualitative  and  one 
quantitative  test,  viz.,  Fehling's  test  and  the  fermentation  test. 

I.  Fehling's  Test. — Mix  in  a  test  tube  equal  parts  of  a  standard 
solution  of  copper  sulphate^  and  a  standard  solution  of  alkaline  tar- 
trates,- and  add  to  this  mixture  an  equal  amount  of  urine.     Mix 

'  Made  by  dissolving  34.64  gm.  pure  CuSO^  in  water  and  then  adding  enough  water  to 
make  500  c.c. 

^  Made  by  dissolving  173  gm.  Rochelle  salts  and  60  gm.  sodic  hydrate  each  in  200  c.c. 
of  water,  mi.xing  the  two  solutions,  and  adding  water  to  make  500  c.c. 


THE  INTESTINE,  SPLEEN,  KIDNEY  401 

and  heat  nearly  to  boiling.  The  amount  of  error  entailed  by  boil- 
ing is  slight  and  unimportant,  but  the  only  advantage  of  boiling  is 
a  slight  saving  of  time.  If  sugar  is  present  a  yellow  or  reddish- 
yellow  precipitate  occurs,  either  at  once  or  (if  the  amount  of  sugar 
is  very  small)  after  the  urine  has  cooled.  Fehling's  solution  may 
also  be  used  for  quantitative  estimation  of  sugar,  but  it  is  more  con- 
venient to  use : 

2.  The  Fermentation  Test. — Take  the  specific  gravity  of  the  urine 
as  carefully  as  possible,  and  acidify  it  if  necessary  with  acetic  acid. 
Pour  six  or  eight  ounces  of  urine  into  a  wide-mouthed  vessel  and 
crumb  into  it  half  a  cake  of  fresh  Fleischmann's  yeast.  Set  the  flask 
aside  in  a  warm  place,  and  after  twenty-four  hours  test  the  super- 
natant fluid  with  Fehling's  solution  as  above;  if  sugar  is  still  present 
fermentation  must  be  allowed  to  go  on  twenty-four  hours  longer.  As 
soon  as  a  negative  reaction  to  Fehling's  has  been  secured  (whether 
in  twenty-four  or  forty-eight  hours),  the  specific  gravity  of  the  fil- 
tered urine  is  again  taken.  ^  It  will  be  found  lower  than  before  the 
fermentation,  and  for  every  degree  of  specific  gravity  lost  we  may 
reckon  that  0.23  per  cent  of  sugar  has  been  fermented  out  of  the 
urine.  Thus  if  the  reading  was  1.040  before  fermentation  and  1.020 
afterward,  we  multiply  the  difference  between  these  readings,  20,  by 
0.23,  giving  4.6  per  cent — the  percentage  of  sugar. 

Fehling's  test  should  be  applied  to  every  urine  examined;  it  takes 
but  a  minute  or  two.  When  it  shows  a  yellow  or  red  precipitate,  the 
fermentation  test  should  also  he  tried;  and  if  both  tests  are  positive  we 
shall  run  but  a  negligible  risk  in  saying  that  glucose  is  present.  From 
the  result  of  the  fermentation  test  and  the  twenty-four-hour  amount 
of  urine,  we  can  estimate  the  daily  output  of  sugar  through  the  urine. 

Permanent  glucosuria  means  diabetes  mellitus.  Transitor}^  glu- 
cosuria  may  be  due  to  a  great  many  causes,  among  which  are:  (i) 
Diseases  of  the  liver;  (2)  diseases  of  the  brain,  organic  or  functional, 
especially  the  latter;  (3)  infectious  fevers;  (4)  poisons,  especially 
narcotics  (alcohol,  chloral,  morphine);  (5)  pregnancy;  (6)  exoph- 
thalmic goitre. 

Experimental  ("alimentary")  glucosuria  or  levulosuria  can  be 
produced  in  many  of  these  same  diseases  by  giving  the  patient  100  gm. 
of  glucose  or  levulose  in  solution. 

The  differential  diagnosis  of  the  cause  of  glucosuria  depends  on 
the  recognit  on  of  one  of  the  above  conditions.     The  other  sugars 

^  The  room  temperature  must  be  approximately  the  same  as  at  the  time  of  the  previous 
reading. 

26 


402  PHYSICAL  DIAGNOSIS 

occasionally  found  in  the  urine  (levulose,  lactose,  pentose,  etc.),  are  of 
no  clinical  importance. 

VI.   The  Acetone  Bodies. 
Acetone,  Diacetic  and  Beta-Oxybutyric  Acids. 

1.  Test  for  Acetone. — To  about  one-sixth  of  a  test  tube  of  urine 
add  a  crystal  of  sodium  nitroprusside,  and  then  NaOH  to  strong 
alkalinity.  Shake  and  add  to  the  foam  a  few  drops  of  glacial  acetic 
acid.     A  purple  color  shows  acetone. 

2.  Test  for  Diacetic  Acid. — A  Burgundy  red  color  when  a  strong 
aqueous  solution  of  ferric  chloride  is  added  to  fresh  urine  (not  pre- 
viously boiled)  in  a  test  tube.  If  this  reaction  is  well  marked  beta- 
oxybutyric  acid  is  probably  also  present,  but  we  possess  no  clinical 
test  for  the  latter  substance. 

Significance  of  the  Acetone  Bodies. — Diminished  utilization  of 
carbohydrate  food  by  the  body  is  usually  the  cause  of  the  appear- 
ance of  these  bodies  in  the  urine.  This  may  occur:  (a)  Because  suf- 
ficient carbodydrates  are  not  eaten  (starvation,  rectal  alimentation, 
fevers,  etc.).  (b)  Because  they  are  not  absorbed  (vomiting,  diar- 
rhoea, etc.).  (c)  Because  they  are  not  assimilated  (diabetes),  and 
rarely  for  other  reasons. 

VII.  Other  Chemical  Tests. 

The  information  to  be  derived  from  testing  for  indican,  for  the 
amounts  of  urea,  uric  acid,  chlorides,  phosphates,  and  sulphates, 
does  not  seem  to  me  sufficient  to  justify  the  time  spent.  The  same 
is  true  of  the  diazo  reaction.  The  guaiac  test  for  blood ,  described  above 
(see  p.  356)  in  connection  with  the  examination  of  gastric  contents 
and  fevers,  is  also  of  value  in  the  urinary  examination. 

Simon's  lucid  arguments  for  the  value  of  the  indican  test  have 
not  been  borne  out  by  my  experience  with  it  in  diagnostic  puzzles. 
The  tests  for  urea  and  uric  acid  are  of  value  only  when  we  possess 
a  knowledge  of  all  the  factors  governing  their  excretion,  knowledge 
which  in  clinical  work  we  almost  never  have.  Diminution  or  ab- 
sence of  the  urinary  chlorides  in  pneumonia  is  not  constant,  and 
occurs  in  many  other  infections  (typhoid,  scarlet  fever,  etc.).  The 
diazo  reaction  is  nearly  constant  in  typhoid,  but  is  occasionally 
found  in  so  many  other  febrile  and  cachectic  states  that  most  clini- 
cians have  ceased  to  rely  on  it.  Its  value  in  the  prognosis  of  phthisis 
is  slight.     I  believe  that  the  general  abandonment  of  the  tests  for 


THE  INTESTINE,  SPLEEN,  KIDNEY  403 

the  sulphates  and  phosphates  will  soon  be  followed  by  the  abandon- 
ment of  the  tests  for  urea,  uric  acid,  indican,  and  the  chlorides. 
The  use  of  these  tests  gives  the  appearance  of  accuracy  and  scientific 
method  in  diagnosis — the  appearance,  but  not  the  reality. 

VIII.   Microscopic  Examination  of  Urinary  Sediments. 

Methods. — A  centrifuge  is  convenient,  but  not  necessary.  The 
sediment  should  be  allowed  to  settle  in  a  conical  glass  (see  Fig.  220), 
whence  a  drop  of  it  can  be  transferred  to  a  slide  by  means 
of  a  pointed  glass  pipette.  Close  the  upper  end  of  this 
with  the  forefinger  and  introduce  the  pointed  end  into 
the  densest  portion  of  the  sediment;  next  very  slightly 
relax  the  pressure  of  the  forefinger  until  urine  and  sedi- 
ment flow  into  the  lower  one-half  or  three-fourths  inch 
of  the   pipette.     Then  resume    firm    pressure    with  the 

forefinger,  withdraw  the  pipette,  wipe  the  outside  of  it         ^^^-  ^^°- 
J  ,.,  .,  .  .,.,  ,  .         Conical  Glass 

dry,  put  its  pomt  upon  a  microscopic  slide,  and  again 

slightly  relax  the  pressure  of  the  forefinger  so  as  to  let  a     Sediments 

small  drop  of  urine  and  sediment  run  out  upon  the  slide. 

Cover  this  drop  with  a  seven-eighths  inch  cover  glass,  and  examine 

it  with  a  Leitz  objective  No.  5  or  Zeiss  DD. 

The  arrangement  of  the  light  is  most  important.  The  iris  dia- 
phragm should  be  closed  until  one  can  just  distinguish  the  outlines 
of  the  cells  and  other  objects  in  the  field.  If  more  light  is  admitted 
the  pure  hyaline  casts  will  be  invisible. 

Results. — The  objects  most  often  sought  for  in  the  sediment  are : 
(a)  Casts;  (b)  cells;  (c)  crystals;  (d)  animal  parasites  or  their  eggs. 

I.  Casts. ^ — Casts,  or  moulds  of  the  renal  tubules,  may  be  homo- 
geneous and  transparent  (hyaline,  Fig.  221,  i)  or  may  have  attached 
to  this  matrix  a  variety  of  granules,  cells,  crystals,  or  fat  drops.  Ac- 
cording to  the  variety  of  passengers  carried  down  from  the  kidney  on 
the  casts,  we  call  them  granular,  brown- granular,  cellular,  blood,  fatty,  or 
crystal-bearing  casts  (see  Fig.  221,  2  and  3,  and  Fig.  222,  i,  2,  3,  and  4). 

Dense  or  highly  refractile  casts,  colorless  or  straw  colored,  are 
occasionally  seen,  and  are  often  given  a  variety  of  names  quite  un- 
justified by  any  knowledge  of  their  composition  (e.g.,  "waxy,"^ 
"fibrinous,"  etc.). 

^  Though  I  have  here  described  casts  first  I  believe  that  the  finding  of  blood  or  pus  in 
the  sediment  is  of  far  more  frequent  and  more  considerable  importance. 

^  Some  dense,  refractile  casts  give  the  amyloid  reaction,  but  this  does  not  indicate 
amyloid  kidneys  and  has  no  knovi^n  clinical  significance. 


404 


PHYSICAL  DIAGNOSIS 


From  strands  of  mucus,  foreign  bodies,  and  other  sources  of  error, 
true  casts  may  be  distinguished  by  the  following  traits : 
[^    ^  (a)   Their  sides  are  parallel. 

(6)  One  end  is  rounded; 
sometimes  both  ends. 

Red  corpuscles  and  other 
cells  upon  casts  are  to  be 
recognized — the  former  by 
the  size,  shape,  and,  if 
fresh,  by  their  color  (pale 
straw) ;  the  latter  by  the 
presence  of  a  nucleus. 

Fat  drops  are  spherical 
and  very  highly  refractile, 
so  that  they  seem  to  have 
a  black  line  at  their  per- 
iphery. 

Crystals   can  be  recog- 
nized by  their  angles.    They 
are  very  rarely  of  importance.     When  showers  of  oxalate  crystals  in 
large  masses  are  associated  with  attacks  of  haematuria  not  otherwise 
explained,  the  crystals  may  be 


Fig.  22  1. — Casts,  i,  Hyaline  casts;  2  and 
hyaline  casts  with  cells  and  blood  adherent; 
"  cylindroids." 


of  some  etiological  significance. 

Other    bodies    on    casts    are 
called  granules. 

Significance  of  Casts. — 
Casts  may  occur  in  health  (un- 
less we  choose  to  class  muscular 
fatigue  as  disease)  as  well  as 
under  any  of  the  conditions  giv- 
ing rise  to  albuminuria  (see  page 
.399).  They  are  usually  more 
numerous  in  acute  nephritis  and 
in  the  acute  exacerbations  of 
chronic  nephritis  than  in  most 
other  conditions.  Any  type  of 
cast  may  occur  in  any  type  of  nephritis,  but 

Cellular,^  blood,   and   brown- granular  casts  are  most  often  found 
in  acute  nephritis. 

^  "Cellular"  is  a  better  term  than  "epithelial,"  since  we  have  no  marks  for  recognizing 
renal  epithelium  or  for  disringuishing  a  renal  cell  from  a  lymphocyte. 


Fig.  222. — Casts,     i,  Blood-casts;  2,  fatty 
casts;  3,  granular  casts;  4,  cellular  casts. 


THE  INTESTINE,  SPLEEN,  KIDNEY 


405 


Fig.    223. 
Spermatozoa. 


Fatty,  highly  refracting,  or  dense  casts  most  often  predominate 
in  chronic  glomerular  nephritis  ("diffuse"  or  "parenchymatous" 
nephritis) . 

Hyaline  and  granular  casts  may  occur  in  any  type  of  nephritis 
and  in  many  other  conditions  (fatigue,  renal  stasis, 
etc.).  In  the  urine  of  persons  over  fifty  years  of  age 
the  presence  of  a  few  hyaUne  and  granular  casts  has 
no  known  clinical  significance,  and  may  probably  be 
considered  physiological. 

Periods  occur  in  the  course  of  many  cases  of 
chronic  interstitial  nephritis  when  no  casts  can  be 
found.  If  any  occur  they  are  usually  of  the  hyaline 
and  fine  granular  types. 

2.   Free   Cells  in    Urinary  Sediment.     A.  Recogni- 
tion.— The  presence  of  macroscopic  pus  or  blood  already  alluded  to 
may  be  verified  by  the  microscope. 

(a)  Fresh  red  cells,  lately  freed  from  the  blood-vessels,  preserve 
their  straw-yellow  color.  Their  presence  points  to  the  recent  effu- 
sion of  blood,  probably  from  the  bladder,  urethra,  or  renal  pelvis. 

(6)  Abnormal  blood,  decolorized 
and  shadowy  red  discs,  can  be 
recognized  with  practice  by  their 
size  and  shape.  We  may  infer 
that  they  have  remained  some 
time  in  the  urine  and  have  proba- 
bly come  from  the  kidney. 

(c)  Pus  is  easily  recognized  as 
a  rule  by  the  presence  of  the  fa- 
miliar polymorphous  nucleus  in 
most  of  the  cells.  Should  doubt 
arise,  a  drop  of  dilute  acetic  acid 
allowed  to  run  under  the  cover 
glass  will  sharpen  the  outlines  of 
the  nuclei  and  facilitate  their  recog- 
nition. 

{d)  Spermatozoa  (see  Fig.  223) 
are  often  seen  in  the  urine  after 
coitus  or  nocturnal  emissions.  They  are  of  no  importance,  except 
that  when  appearing  in  the  urine  of  females  they  may  afford  valuable 
medico-legal  evidence.  They  are  easily  recognized  by  their  size  and 
shape. 


Fig.  224. — Crystals  of  Triple  Phosphate 
(prisms)  and  Ammonium  Urate  (small 
spheres  with  spines.) 


406 


PHYSICAL  DIAGNOSIS 


i  0 


xf 


Fig.  225. — Crystals  of  Uric  Acid  (whet- 
stone-shaped) with  Calcic  Oxalate  (small 
octahedral)  and  Amorphous  Urates. 


(e)  Other  varieties  of  cells  need  not  be  dififerentiated,  since  almost 
any  of  the  varieties  usually  described  {squamous,  spindle-shaped, 
caudate,  etc.)  may  come  from  any  part  of  the  urinary  tract.  Renal 
cells  are  not  recognizable  by  our  present  methods  of  examination. 

Any  of  the  urinary  cells  may 
contain  fat  drops,  but  these  have 
no  special  diagnostic  significance. 
B.  Interpretation. — The  sig- 
nificance of  large  quantities  of 
blood  or  of  pus  in  the  urine  has 
already  been  discussed  (page 
395).  When  recognizable  only 
by  the  microscope  they  have  no 
diagnostic  value. 

The  presence  of  large  num- 
bers of  cells  not  coming  from  the 
blood-vessels  (squamous,  spin- 
dle-shaped, etc.)  is  usually  asso- 
ciated with  cystitis,  provided  the 
accidental  admixture  of  vaginal 
detritus  is  excluded.  Pyelitis 
and  renal  suppurations  may  fill  the  sediment  with  similar  cells, 
and  only  by  other  methods  of  examination  (cystoscopy,  ureteral 
catheterization)  and  by  taking  account  of  all  the  facts  in  the  case 
can  the  differentiation  be  made. 

3.  Crystals  in  Urinary  Sedi- 
ments (see  Figs.  224,  225,  and  226). 
— The  varieties  oftenest  seen  are: 
(a)  Triple  phosphate  (ammoniacal 
urine,  cystitis) ;  (6)  ammonium 
urate;  (c)  uric  acid;  {d)  calcic 
oxalate. 

All  of  these  varieties  are  color- 
less except  the  uric-acid  crystals, 
which  are  usually  light  or  dark 
yellow  or  yellowish-brown. 

None  of  these  have  much  significance  in  diagnosis.  The  first 
two  merely  confirm  the  evidence  of  urinary  decomposition  (usually 
from  cystitis)  afforded  by  the  reaction,  turbidity,  and  odor  of  the 
urine. 

Uric-acid    crystals,    if    present    in    great    numbers   in   the    urine 


Fig.  226. — Calcic  Oxalate  Crystals. 


THE  INTESTINE,  SPLEEN,  KIDNEY 


407 


when  passed,  suggest  the  search  for  macroscopic  masses  (gravel) 
and  for  other  evidence  of  renal  stone,  but  as  a  rule  they  are  of  no 
importance. 

The  same  may  be  said  of  calcium  oxalate.     Oxaluria  is  one  of  the 
most  persistent  bugbears  of  the  medical  profession,  but  it  is  utterly 


Fig.  227. — ^Vinegar  Eels  in  Urine.  (Billings.)  a,  Protruded  hooks  of  male;  b,  top- 
shaped  oesophageal  enlargement.  The  Strongyloides  stercoralis  (see  above,  Fig.  215,  page 
3 85)  has  also  been  found  in  the  urine. 


harmless  except  in  the  rare  cases  in  which  it  accompanies  hsematuria 
(see  above)  or  gravel. 

4.  Animal  parasites  or  their  eggs  are  occasionally  found  in  the 
urine,  with  or  without  haematuria  and  evidence  of  cystitis  (see  Figs. 
227  and  228). 


408 


PHYSICAL  DIAGNOSIS 


Summary  of  the  Urinary  Pictures  Most  Useful  in  Diagnosis. 

Aside  from  polytiria,  oliguria,  hcsmat^iria,  and  pyuria,  which 
have  already  been  discussed,  the  most  important  conditions  in  which 
the  urine  gives  valuable  diagnostic  evidence  are: 

I.  Cystitis. — Urine  passed  frequently,  painfully,  and  in  small 
amounts.  Turbid,  ammoniacal,  and  offensive  (after  the  earliest 
stages).  Much  pus  and  many  other  cells  are  found  in  the  sediment, 
with  bacteria,  triple  phosphate  crystals,  and  amorphous  debris.     It 


wrr 


-  / 


Fig.  228. — Bilharzia  Eggs  in  the  Urine,  with  Blood,  Calcic  Oxalate,  and  a  Hyaline  Cast. 

(O'Neil.)  _ 


must  be  remembered  that  cystitis  is  usually  but  one  element  in  the 
diagnosis;  bladder  stone,  obstructing  prostate,  tuberculous  kidney,  or 
other  diseases  may  be  its  cause. 

2.  Acute  Nephritis  (or  acute  exacerbations  in  chronic  cases). — 
Scanty,  heavy,  highly  albuminous  urine,  often  bloody  and  containing 
in  the  sediment  much  blood  and  many  cells,  free  or  on  casts.  Other 
varieties  of  casts  occur,  but  are  not  characteristic.  In  convalescence 
the  urine  becomes  abundant  and  of  light  weight,  and  the  other 
abnormalities  gradually  disappear. 

3.  Chronic  Glomerular  Nephritis  ("parenchymatous"). — The  urine 
is   rather   scanty,    pale,    and   of  light   weight    (1.012-1.018),   with    a 


THE  INTESTINE,  SPLEEN,  KIDNEY  409 

large  amount  of  albumin  and,  in  the  sediment,  much  fat — free,  in 
cells,  and  on  casts.  Also  found,  but  not  characteristic,  are  all  the 
other  varieties  of  casts.  If  death  does  not  ensue  within  eighteen 
months,  the  urine  is  apt  to  assume  the  characteristics  of  the: 

4.  Contracted  kidney  (primary,  secondary,  or  arterio-sclerotic), 
with  polyuria  (often  several  quarts;  urine  especially  abundant  at 
night),  low  specific  gravity  (i.oio  or  less).  Traces  of  albumin  and 
a  few  hyaline  and  granular  casts  occur  steadily  or  intermittently. 
High  blood  pressure  is  nearly  constant. 

5.  Pyelitis  and  acute  hcematogenous  renal  suppurations  are  dis- 
eases much  more  commonly  recognized  since  1904  than  previously. 
The  presence  of  bacteria  (usually  colon  bacilli)  and  pus  without  many 
cells  of  other  types  in  acid  urine  should  always  lead  to  bacteriological 
and  cystoscopic  examinations.  This  condition  of  the  urine  may 
at  times  be  the  only  sign  of  the  disease.  The  presence  of  pain,  tender- 
ness, or  tumor  in  the  region  of  the  kidney  (usually  the  right  kidney) 
and  the  occurrence  of  fever  and  leucocytosis  support  the  diagnosis, 
especially  in  children  and  in  women  near  parturition.  To  distinguish 
pure  pyelitis  from  pyelitis  complicating  a  renal  infection  is  at  present 
impossible. 

This  disease  should  be  borne  in  mind : 

(a)  In  all  cases  of  unexplained  fever  without  obvious  local  cause — 
especially  in  girl  babies  and  in  women  a  short  time  before  or  after 
parturition  (subacute  or  chronic  renal  infection). 

(b)  In  acute  abdominal  emergencies  when  appendicitis,  chole- 
cystitis, intestinal  obstruction,  perforating  peptic  ulcer,  and  pan- 
creatitis are  being  considered.  With  these  consider  also  acute  infection 
of  the  kidney,  for  in  some  cases  the  pain  is  in  the  right  hypochondrium 
and  no  complaints  suggesting  the  kidney  are  uttered. 


CHAPTER  XXII. 

THE  BLADDER,  RECTUM,  AND  GENITAL 

ORGANS. 

The  Bladder. 

Incidence  of  Bladder  Disease. 

(Massachusetts  General  Hospital,   1 870-1 905.) 

Cystitis 829  cases. 

Stone 538  cases. 

Cancer 57  cases. 

Papilloma 20  cases. 

Tuberculosis 43  cases. 

Data. 

Distention,  tumor,  the  urine,  and  the  results  obtained  by  cystos- 
copy, by  catheterization,  by  rectal  and  vaginal  examination,  by  the 
x-ray,  and  by  sounding  for  stone  furnish  most  of  our  direct  evidence 
in  bladder  disease.  Pain  in  the  bladder  or  near  the  end  of  the  penis, 
and  frequent,  painful  micturition  with  vesical  tenesmus  or  straining, 
are  common  symptoms  in  various  lesions  of  the  organ,  and  direct 
our  attention  to  it,  though  they  do  not  indicate  the  nature  of  the 
trouble. 

/.   Distention  of  the  Bladder. 

In  both  sexes,  distention  is  often  wholly  unknown  to  the  patient, 
and  may  be  accompanied  by  frequent  acts  of  urination,  especially 
in  prostatic  obstruction,  in  acute  infections,  and  after  operations.  A 
distended  bladder  is  readily  recognized  by  palpation  as  a  smooth, 
round,  firm,  symmetrical  tumor  in  the  median  line,  above  the  pubes. 
The  tumor  is  dull  on  percussion,  and  in  slight  degrees  of  distention 
this  dulness  above  the  pubes  may  be  the  only  physical  sign  obtainable. 
In  well-marked  cases,  which  are  most  common  in  males,  the  distended 
bladder  may  reach  to  the  navel  or  even  above  it,  and  the  beginner  is 
usually  astonished  at  its  dimensions  and  its  firm,  resistant  surface  (see 

410 


THE  BLADDER,  RECTUM,  AND  GENITAL  ORGANS 


411 


Fig.  229).  Diagnosis  rests  on  the  infrequency  of  other  tumors  of 
this  region  in  men  and  on  the  result  of  catheterization  or  suprapubic 
aspiration.  In  females  a  history  of  failure  to  pass  urine  almost 
invariably  makes  the  diagnosis  obvious,  though  occasionally  after 
operations  distention  of  the  bladder  and  dribbling  of  urine  may  go 
together  in  women,  as  they  so  frequently  do  in  men. 
The  commonest  causes  of  distended  bladder  are : 
(i)  Prostatic  hypertrophy,  alone  or  combined  with 

(2)  Old  strictures  of  the  urethra. 
Less  common  are : 

(3)  Spasm  of  the  urethra  in  gonorrhcea. 

(4)  Acute  prostatitis. 


Fig.  229. — Distended  Bladder  Reaching  Above  the  Navel. 


(5)  Paralysis  of  the  bladder,  from  disease  or  injury,  after  opera- 
tion, and  m  fevers. 

(6)  Tumor  or  stone  near  the  neck  of  the  bladder. 

The  diagnosis  of  the  cause  of  distention  rests  on  the  history,  the 
result  of  attempts  at  catheterization,  the  rectal  examination,  the 
condition  of  the  urine,  and  the  physical  signs  in  other  parts  of  the 
body.  A  long  history  of  frequent  micturition,  especially  at  night,  in 
an  old  man,  an  obvious  enlargement  of  the  prostate  felt  by  rectum, 


412  PHYSICAL  DIAGNOSIS 

and  the  passage  of  ammoniacal  urine  suggest  prostatic  obstruction. 
The  information  obtained  during  the  passage  of  a  catheter  usually 
clinches  the  diagnosis. 

Acute  retention,  with  no  previous  history  of  frequent  micturition  or 
foul-smelling  urine  in  a  young  or  middle-aged  man,  who  has  had 
gonorrhoea  and  may  or  may  not  have  noticed  a  diminution  in  the 
size  of  the  stream  of  urine  passed,  suggests  a  urethral  stricture.  The 
catheter  decides. 

Spasm  of  the  urethra  may  occur  in  acute  gonorrhoea,  and  pro- 
duces a  retention  which  may  often  be  ovei-come  by  hot  poultices  and 
enemata.  The  history  and  the  effects  of  treatment  suggest  the 
cause  of  the  retention. 

Acute  prostatitis,  as  a  cause  of  retention  following  gonorrhoea, 
is  suggested  by  pain  and  tenderness  in  the  perineum,  painful  defe- 
cation, fever,  perhaps  chills,  and  a  hot,  tender  prostate  felt  by  rectum. 
Abscess  may  form  and  discharge  by  urethra  or  rectum. 

Paralysis  of  the  bladder,  as  a  cause  of  retention,  is  usually  obvi- 
ous from  the  history  and  from  the  evidence  of  disease  of  the  spinal 
cord,  or  of  operation  and  semicomatose  states  (as  in  fevers  and  shock). 

Tumors  of  the  bladder  are  suggested  by  intermittent  haematuria 
with  vesical  irritation,  and  confirmed  by  cystoscopic  examination. 

II.   The   Urine  as  Evidence  of  Bladder  Disease. 

This  has  been  described  above  (page  408).  Cystitis,  acute  or 
chronic,  usually  gives  characteristic  evidence  of  itself  in  the  urine, 
and  suggests  as  its  cause  the  possibility  of  gonorrhoea,  of  vesical  stone, 
of  prostatic  or  other  obstruction  to  the  outflow,  and  of  vesical  or 
renal  tuberculosis.  When  a  urine  like  that  of  chronic  interstitial 
nephritis  occurs  with  chronic  prostatic  obstruction,  the  relief  of  the 
obstruction  is  necessary  if  we  are  to  prevent  progressive  development 
of  cirrhotic  kidney  from  back  pressure. 

Frequent  micturition  is  much  commoner  and  less  significant  in 
women  than  in  men.  All  sorts  of  "nervousness"  and  emotional 
strain  produce  this  symptom  in  women,  independent  of  any  demon- 
strable source  of  irritation  in  the  urinary  tract.  Aside  from  these 
conditions  the  symptom  is  oftenest  met  with  in : 

(a)  Cystitis,  from  any  cause,  including  stone  and  renal  tuberculosis, 
or  without  know^n  cause,  with  characteristic  changes  in  the  urine. 

(&)   Prostatic  obstruction,  with  evidence  of  retention. 

(c)   Gonorrhoea,  with  evidence  of  this  disease. 

(f/)   Paralysis  of  the  bladder  (see  above) . 


THE  BLADDER,  RECTUM,  AND  GENITAL  ORGANS  413 

(e)  Overconccnfration  of  the  urine  (estimated  by  the  color  and 
specific  gravity) . 

///.  Stone  in  the  Bladder. — Pain  near  the  end  of  the  penis,  espe- 
cially, at  the  end  of  micturition  and  aggravated  by  jolting  or  active 
motion,  frequent  urination,  especially  in  the  daytime,  sudden  inter- 
ruption of  the  stream  of  urine,  and  hsematuria  at  the  end  of  micturi- 
tion, are  the  most  frequent  symptoms  of  stone,  especially  if  they 
occur  in  boys.  In  old  men  stone  may  be  wholly  without  character- 
istic symptoms,  and  at  any  age  the  symptoms  can  never  do  more 
than  suggest  the  possibility  of  stone  and  the  advisability  of  search- 
ing for  it  systematically  with  a  proper  sound. 

IV.  Tuberculosis  of  the  Bladder. — Cystoscopy  and  the  recogni- 
tion of  tubercle  bacilli  by  animal  inoculation  are  the  only  reliable 
means  of  diagnosis.  A  chronic  cystitis  in  a  young  or  middle-aged 
person,  especially  with  an  acid  urine,  is  suggestive. 

The  Rectum. 

It  is  not  and  should  not  be  a  part  of  routine  physical  examina- 
tion to  examine  the  rectum.  The  commonest  conditions  which  call 
for  such  investigation  are : 

(a)   Hemorrhage  at  stool. 

{h)  The  protrusion  after  defecation  of  something  which  is  not 
easily  returned  ("piles")- 

(c)  Painful  defecation  or  pain  in  the  region  of  the  rectum  at 
other  times. 

{d)   The  presence  of  an  ulcer  or  sinus  near  the  rectum. 

{e)    Habitual  constipation,  not  explained  by  lesions  elsewhere. 

(/)    Intestinal  obstruction. 

(g)   All  subacute  diarrhoeas  of  elderly  persons  (cancer) . 

{h)  Suspected  appendicitis,  prostatitis,  prostatic  tumor  or  ob- 
struction, or  diseases  of  the  seminal  vesicles. 

{i)    Pelvic  symptoms  in  women  with  tight  hymen. 

The  diseases  of  the  rectum  which  we  are  especially  on  the  look- 
out for  are:  (i)  Hemorrhoids;  (2)  fissure  of  the  anus;  (3)  ischio- 
rectal abscess;  (4)  fistula  in  ano;  (5)  cancer  of  the  rectum.  Less 
common  are:  (6)  pruritus  ani;  (7)  prolapse  of  the  rectum;  (8)  ulcera- 
tion or  stricture  of  the  rectum. 

Methods. 

For  most  examinations  the  finger  suffices.  It  should  be  covered 
by  a  thin,  rubber  finger-cot,  greased  with  vaseline,   and  should  be 


414  PHYSICAL  DIAGNOSIS 

introduced  slowly  and  gently  while  the  patient  strains  down  as  dur- 
ing defecation. 

The  examining  finger  should  note  the  presence  of  abnormal 
prominences  or  resistance  (piles,  tumors)  in  any  part  of  the  rectum-, 
of  tender  spots  (ulcer,  abscess),  and  strictures.  The  shape  and  size 
of  the  prostate  gland,  its  consistence,  and  the  presence  or  absence 
of  tenderness  in  it  are  of  importance.  The  normal  seminal  vesicles 
can  be  felt  if  distended.  If  they  are  hard  and  nodular,  tuberculosis 
should  be  suspected. 

High  up  on  the  right  side  the  finger  may  touch  a  tender  spot  if 
an  inflamed  appendix  is  near  the  pelvic  brim. 

In  women  the  uterus,  especially  if  retroverted,  may  be  easily 
felt,  and  most  of  the  other  details  of  pelvic  examination  (see  below, 
page  419)  can  be  more  or  less  clearly  made  out. 

For  higher  and  more  thorough  examination  a  cylindrical  specu- 
lum and  a  head  mirror  should  be  used,  with  the  patient  in  the  knee- 
chest  position. 

Hemorrhoids. — The  diagnosis  of  external  hemorrhoids,  which  can 
easily  be  brought  outside  the  anus,  is  made  at  a  glance.  Internal 
hemorrhoids  are  best  seen  with  a  rectal  speculum,  and  may  resemble 
the  external  or  may  consist  of  "bright  red,  spongy,  granular  tumors, 
rarely  larger  than  a  ten-cent  piece,  and  situated  high  up  in  the  rectum  " 
(ncevoid  piles) . 

Fissure  of  the  anus  is  often  connected  with  a  small  ulcer  and  with 
oedematous  folds,  which  resemble  an  external  pile  but  are  much 
more  tender.  On  separating  these  folds  the  fissure  comes  into  sight. 
It  produces  severe  pain  during  and  after  defecation. 

Ischio-rectal  abscess  presents  near  the  anus  the  ordinary  signs  of 
abscess  with  pain  radiating  through  the  pelvis,  but  may  open  either 
within  or  outside  the  rectum  and  results  in 

Fistula  in  ano,  a  sinus  beside  the  rectum,  opening  internally, 
externally,  or  in  both  directions.  It  may  be  very  tortuous  and  need 
examination  with  speculum  and  probe.  Tuberculosis  is  always  to  be 
suspected  in  such  fistulse. 

Cancer  of  the  rectum  is  suggested  by  the  occurrence  of  rectal  pain 
during  defecation,  with  blood  in  the  stools  and  either  diarrhoea  or 
constipation,  usually  with  some  pallor  and  emaciation,  in  persons  past 
middle  life.  Owing  to  neglect  of  a  thorough  examination  many  cases 
are  at  first  mistaken  for  piles. 

The  examining  finger  reaches  a  hard,   ulcerating  mass  high  up. 


THE  BLADDER,  RECTUM,  AND  GENITAL  ORGANS  415 

as  a  rule,  in  the  rectum.     It  may  be  easier  to  reach  if  the  patient 
stands  or.  squats  and  strains  down  during  examination. 

From  tuberculous  or  benign  stricture  with  or  without  ulceration, 
and  from  benign  villous  grow^ths,  it  may  be  impossible  to  distin- 
guish cancer  without  histological  examination  of  an  excised  piece. 
Tumors  of  the  prostate  are  felt  on  the  anterior  wall  of  the  rectum 
and  practically  never  ulcerate.  They  are  often  very  difficult  to 
recognize. 

The  Male  Genitals. 

Routine  examination  of  the  male  genitals  includes  investigation 
of  the  penis  for  the  presence  of : 

(a)   Urethral  discharge  and  its  consequences. 
(6)   Chancre. 

(c)  Chancroid. 

(d)  Balanitis. 

(e)  Phimosis  or  paraphimosis. 
(/)  Periurethral  abscess. 

(g)   Malformations. 

(h)   Cancer. 

In  the  testes  and  scrotum  we  look  for  : 

(a)  Epididymitis  (gonorrhoeal  or  tuberculous). 

(b)  Orchitis  (traumatic,  syphilitic,  tuberculous,  after  mumps  and 
other  infections). 

(c)  Tumors  of  the  testis  (cancer  or  sarcoma) . 

(d)  Hydrocele  and  haematocele. 

(e)  Varicocele. 

(/)   Scrotal  hernia. 

(g)   Absence  of  one  or  both  testes. 

The  Penis. 

Urethral  discharge,  if  not  obvious,  may  often  be  brought  to  light 
by  "stripping"  the  urethra  forward  from  the  prostatic  region  to  the 
meatus.  If  Gram's  stain  brings  out  an  intracellular,  decolorizing 
diplococcus  in  the  exudate,  there  is  no  reasonable  doubt  of  the  pres- 
ence of  gonorrhoea. 

Chancre  ("hard  sore"),  the  primary  syphiHtic  lesion,  is  a  super- 
ficial, painless,  indolent  ulcer  with  an  indurated  base  and  a  scanty 
serous  discharge.  It  is  usually  round  or  oval  and  sharply  demarked 
from  the  surrounding  tissue  by  elevated  edges.     It  is  rarely  multi- 


416  PHYSICAL  DIAGNOSIS 

pie.  Painless,  hard,  non-suppurating  buboes  accompany  it.  The 
glans  and  the  inner  surface  of  the  prepuce  are  the  commonest  sites. 
The  Treponema  pallidum  can  often  be  identified  in  stained  smears 
or  by  the  dark  field  illumination.  In  a  certain  percentage  of  cases 
a  positive  Wassermann  reaction  may  be  obtained. 

Chancroid  ("soft  sore")  is  like  any  other  painful,  superficial 
ulcer  without  induration,  irregular  in  shape,  often  multiple,  and 
with  abundant  discharge.  A  single,  painful  bubo  accompanies  it  in 
about  one-third  of  all  cases. 

Balanitis  (inflammation  of  the  surface  of  the  glans  penis),  usu- 
ally gonorrhoeal,  has  the  ordinary  signs  of  inflammation;  it  often 
spreads  to  the  inner  surface  of  the  prepuce. 

Phimosis  is  a  contraction  of  the  orifice  of  the  prepuce,  so  that  it 
connot  be  retracted  to  uncover  the  glans.  May  be  hereditary  or  the 
result  of  gonorrhoea. 

In  paraphimosis  the  prepuce  is  caught  behind  the  glans  penis  so 
that  it  cannot  be  brought  forward.  Great  oedema  of  the  neighbor- 
ing parts  usually  results. 

Peri-urethral  abscess,  usually  a  complication  of  gonorrhoea,  ap- 
pears as  a  small,  tender  swelling  on  the  under  surface  of  the  urethra. 

Malformations  are  chiefly  hypospadias  or  congenital  deficiency  of 
some  portion  of  the  lower  wall  of  the  urethra,  and  epispadias  (rare), 
a  similar  deficiency  in  the  upper  wall.  A  short,  downward  curved 
penis  is  often  associated  with  hypospadias. 

Cancer  of  the  penis  attacks  the  foreskin  or  the  glans,  and  has  the 
usual  characteristics  of  epithelioma  elsewhere. 

The  Testes  and  Scrotum. 

Acute  epididymitis,  usually  a  complication  of  gonorrhoea,  appears 
as  a  hot  and  tender  swelling  behind  the  testis,  often  preceded  by 
tenderness  along  the  spermatic  cord.  Acute  hydrocele  may  accom- 
pany it. 

Chronic  epididymitis,  usually  tuberculous,  is  painless  and  insid- 
ious in  onset,  and  produces  a  hard,  irregular  enlargement  low  down 
behind  one  or  both  testes,  to  which,  however,  the  process  is  apt  soon 
to  spread.  Caseation  and  involvement  of  the  skin. later  produce  a 
suppurating  sinus,  which  is  often  the  first  thing  to  bring  the  patient 
to  a  physician. 

Acute  orchitis  is  often  due  to  a  blow,  to  gonorrhoea,  or  to  mumps. 
The  testis  is  symmetrically  swollen  and  tender,  but  suppuration 
rarely  follows. 


THE  BLADDER,  RECTUM,  AND  GENITAL  ORGANS  417 

Chronic  orchitis',  often  syphilitic,  is  slow,  painless,  and  may  be 
accidentally  discovered  as  a  slightly  irregular  induration  of  the  testes 
with  little  if  any  increase  in  size.  Ulceration  and  fistulse  are  rare  in 
the  syphilitic  form,  common  in  the  tuberculous. 

Cancer  of  the  testis  may  appear  at  any  age.  It  is  soft,  almost 
fluctuating,  and  grows  very  rapidly,  soon  involving  and  perforat- 
ing the  skin,  so  as  to  produce  an  offensive,  fungous,  granulating  out- 
growth which  easily  bleeds.     The  inguinal  glands  are  involved. 

Sarcoma  of  the  testis,  commonest  at  puberty,  produces  a  painless, 
uniform  enlargement,  and  may  reach  great  size.  It  may  resemble 
hydrocele  or  hsematocele  and  be  mistaken  for  the  latter,  especially 
for  an  old  effusion  in  a  thickened  sac  (see  below). 

Diagnosis  depends  on  rapid  growth,  the  entire  absence  of  trans- 
lucency,  the  tendency  to  adhere  to  the  skin  and  to  present  unequal 
resistance  in  different  portions  (Jacobson).  Incision  should  be  made 
in  all  doubtful  cases. 

Hydrocele,  an  accumulation  of  serous  fluid  in  the  tunica  vagi- 
nalis, may  depend  on  trauma  or  on  an  acute  epididymitis  or  orchitis, 
but  is  usually  chronic  and  of  unknown  cause.  It  may  be  congenital 
and  communicate  with  the  peritoneal  cavity  or  form  part  of  a  general 
dropsy  in  heart  or  kidney  disease. 

Examination  shows  a  smooth,  tense,  fluctuating  tumor,  without 
impulse  on  cough,  usually  without  pain,  tenderness,  or  any  sign  of 
inflammation,  and,  above  all,  translucent  if  examined  with  a  hydro- 
scope  tube  or  in  a  dark  room  with  a  candle. 

If  the  fluid  is  opaque  or  bloody,  or  if  the  tunica  is  thickened, 
there  may  be  no  translucency  and  diagnosis  may  be  impossible 
without  puncture.  The  testis  lies  behind  the  effusion  and  near  its 
lower  end. 

Hematocele  usually  follows  injury  and  produces  a  heavy,  opaque, 
non-fluctuating  tumor,  which  may  closely  resemble  sarcoma  unless 
the  history  and  evidence  of  trauma  are  clear.  Incision  or  puncture 
should  decide. 

Varicocele,  an  enlargement  of  the  veins  about  the  spermatic  cord 
and  vas  deferens,  is  easily  recognized  as  a  mass  of  tortuous  vessels, 
generally  in  the  left  side.     It  often  complicates  hypernephroma. 

Scrotal  hernia  is  usually  reducible,  tympanitic  on  percussion 
and  gives  an  impulse  on  coughing.  If  it  consists  largely  of  omen- 
tum it  will  be  dull  on  percussion.  The  history  of  the  case  and  the 
progression  of  the  tumor  from  above  downward  usually  make  its 
origin  clear. 

27 


418  PHYSICAL  DIAGNOSIS 

Absence  of  one  or  both  testes  from  the  scrotum  should  direct  our 
search  upward  to  the  inguinal  canal,  since  a  retained  testis  may  be 
the  seat  of  troublesome  inflammation  or  of  malignant  disease.  (For 
examination  of  the  seminal  vesicles,  see  the  Rectum,  page  413.) 

The  Female  Genitals. 
Methods. 

Inspection  of  the  external  genitals  is  easy  if  the  parts  are  properly 
exposed  by  a  satisfactory  position  and  a  good  light.  Intravaginal 
inspection  needs  a  speculum  (Sims'  or  bivalve)  and  usually  an  assistant 
to  hold  it. 

Palpation  should  always  be  bimanual,  the  left  forefinger  in  the 
vagina  (or  in  the  rectum  if  the  hymen  is  narrow),  the  right  hand 
above  the  symphysis  pubis.  The  proper  co-operation  of  the  hands 
is  hard  to  describe  and  depends  on  practice.  The  pressure  of  the 
external  hand  helps  to  bring  the  pelvic  organs  within  reach  of  the 
examining  finger  in  the  vagina.  Unless  the  organs  can  be  thus 
grasped  or  balanced  between  the  outer  and  inner  hands,  no  satisfac- 
tory examination  is  possible.  Tenderness  may  prevent  this  or  render 
an  anaesthetic  necessary,  but  gentleness  and  the  avoidance  of  any 
sudden  or  rapid  motions  do  much  to  facilitate  the  examination. 
The  left  hand,  in  making  its  way  into  the  upper  parts  of  the  vaginal 
vault,  should  press  only  on  the  perineum,  avoiding  the  region  of 
the  clitoris.  It  is  astonishing  how  much  pressure  can  be  borne 
without  pain,  provided  it  is  exerted  gradually  and  upon  the  peri- 
neum only.  Many  examiners  find  it  advantageous  to  rest  the  left 
foot  upon  a  stool,  with  the  left  elbow  on  the  knee. 

Lesions. 

I.  In  the  external  genitals  one  looks  for  some  of  the  same 
lesions  already  described  on  page  415,  viz.,  chancre,  chancroid,  local 
inflammations,  and  tumors.  Only  the  commonest  and  most  impor- 
tant lesions  will  be  mentioned  here. 

(a)  In  young  children  a  suppurating  vulvo-vaginitis,  usually 
gonorrhoeal,  but  non- venereal,  is  easily  recognized  by  the  abundant 
purulent  discharge. 

(6)  Local  eczema,  often  red  and  angry,  is  commonly  the  result 
of  the  irritation  of  diabetic  urine  or  a  leucorrhoeal  discharge. 

(c)  Varicose  veins  and  oedema  of  the  vulva  are  common  in  preg- 
nancy and  occasionally  result  from  large  pelvic  tumors. 


THE  BLADDER,  RECTUM,  AND  GENITAL  ORGANS  419 

(d)  Ruptured  perineum,  with  more  or  less  protrusion  of  the  vaginal 
walls,  carrying  with  it  the  bladder  (cystocele)  or  rectum  (rectocele), 
is  readily  recognized  if  the  normal  anatomy  of  the  parts  is  familiar. 

{e)  The  hymen  may  be  imperforate  with  retention  of  menstrual 
fluid,  or  tender,  irritated  remains  of  it  after  rupture  may  cause  pain 
and  need  removal. 

(/)  Urethral  caruncle  (a  small  vascular  papilloma  at  the  entrance 
of  the  urethra)  is  a  bright  red  excrescence,  usually  the  size  of  a  split 
pea  or  smaller.  It  may  cause  no  symptoms  or  may  produce  irritation, 
especially  during  micturition. 

(g)  Small  abscesses  of  the  glands  within  or  around  the  urethra 
may  cause  pain  in  coitus  or  during  micturition. 

II.  The  Uterus. — Only  the  commonest  lesions  will  be  dealt 
with  here,  viz. : 

1.  Laceration  and  "erosion"  of  the  cervix. 

2.  Malpositions  of  the  organ. 

3.  Endometritis. 

4.  Cancer  of  the  uterus. 

5.  Fibro-myoma  of  the  uterus. 

1 .  (a)  Lacerations  of  the  cervix  following  childbirth  are  very  common 
and  frequently  produce  no  symptoms.  They  are  readily  recognized 
by  inspection  and  palpation,  and  are  often  combined  with : 

{b)  "Erosions,"  an  ulcerated,  raw  surface  at  and  around  the  os 
uteri,  with  or  without  the  formation  of  small  cysts.  At  times  the 
OS  assumes  a  warty,  irregular  appearance,  suggesting  cancer,  from 
which  it  can  be  distinguished  only  by  histological  examination  of  an 
excised  piece. 

2.  (a)  Malpositions  (backward  or  forward)  may  involve  the 
whole  organ  (ante-  or  retroversion)  or  represent  a  bending  of  the 
organ  upon  itself  (ante-  or  retroflexion).  These  lesions  may  be 
variously  combined  and  frequently  exist  without  producing  any  symp- 
toms. Indeed,  it  is  doubtful  whether  there  is  any  single  "normal" 
position  for  the  uterus.  Its  position  is  recognized  by  bimanual  pal- 
pation, which  should  also  determine  whether  the  uterus  is  freely 
movable  or  whether  it  is  bound  in  place  by  adhesions,  such  as  are 
very  often  found  with  backward  displacements. 

{b)  Prolapse  of  the  uterus  toward  the  vaginal  outlet  is  often  a 
result  of  pelvic  lacerations  unrepaired.  When  the  uterus  is  outside 
the  vaginal  outlet,  we  call  the  condition  procidentia. 

(c)  Lateral  displacement  of  the  uterus  by  pressure  of  tumors  or 
traction  by  old  adhesions  is  less  common. 


420  PHYSICAL  DIAGNOSIS 

3.  Endometritis  may  present  no  definite  physical  signs  except  a 
muco-purulent  discharge  (leucorrhoea,  "whites")  and  perhaps  un- 
duly frequent,  profuse,  or  prolonged  menstruation.  The  slightest 
touch  of  a  uterine  sound  may  produce  bleeding.  It  often  accom- 
panies disturbances  of  digestion  and  neurasthenic  conditions,  prob- 
ably as  part  of  a  general  prostration  rather  than  as  its  cause. 

4.  Cancer  of  the  tderus  usually  attacks  the  cervix,  and  in  marked 
cases  is  easily  recognized  by  sight  and  touch  as  a  "  cauliflower  "- 
like,  /ungating  mass  on  the  cervix.  In  its  early  stages  it  may  be 
confounded  with  "erosions"  and  inflammatory  conditions,  and  only 
microscopic  examination  can  satisfactorily  determine  its  nature. 
Profuse  hemorrhage,  especially  in  a  woman  about  the  period  of  the 
menopause,  and  the  offensive  odor  of  the  discharge  suggest  the  diag- 
nosis. The  vaginal  wall  is  soon  involved  in  the  growth,  and  irrita- 
bility or  obstruction  in  bladder  or  rectum  may  result.  Cancer  of  the 
fundus  is  suspected  from  the  finding  of  enlargement  or  a  suspicious 
discharge,  but  confirmed  only  by  the  histological  examination  of  bits 
removed  by  curretting. 

5.  Fibro-myoma  of  the  uterus  is  by  far  the  commonest  tumor  of 
that  organ.  It  produces  hemorrhages  at  or  between  the  menstrual 
periods,  and  ansemia  results.  Otherwise  its  effects  are  those  of 
pressure  on  the  bladder  and  rectum,  or  on  neighboring  nerves  or 
vessels  (pain,  oedema). 

Bimanual  palpation  determines,  first  of  all,  the  fact  that  the 
growth  is  connected  and  moves  with  the  uterus.  This  determined 
and  cancer  excluded  by  the  absence  of  any  involvement  of  the  cervix 
or  of  the  vaginal  wall,  the  chief  difficulty  may  be  in  distinguishing 
the  growth  from  a  pregnant  uterus.  Usually  its  irregular  shape, 
the  persistence  of  menses,  and  the  lapse  of  time  settle  the  question. 

Lengthening  of  the  uterine  canal  is  an  important  confirmatory 
sign  of  fibromyoma,  but  sounds  should  never  be  passed  to  determine 
this  fact  unless  pregnancy  can  be  definitely  excluded. 

III.  Fallopian  Tubes. — Salpingitis  (acute  or  chronic)  and  tubal 
pregnancy  are  the  most  important  diseases  of  the  tubes. 

(a)  Salpingitis  is  usually  gonorrhoeal,  occasionally  tuberculous, 
sometimes  of  unknown  origin.  A  painful,  tender  swelling  or  in- 
duration in  the  region  of  the  tube,  with  or  without  fever,  chill,  or 
leucocytosis,  constitutes  the  evidence  for  diagnosis.  From  pelvic 
peritonitis  of  the  tubal  region  diagnosis  is  impossible. 

From  tubal  pregnancy  diagnosis  may  be  very  difficult,  and  sus- 
picions are  rarely  aroused  until  rupture  occurs  {vide  infra).     If  the 


THE  BLADDER,  RECTUM,  AND  GENITAL  ORGANS  421 

signs  and  symptoms  of  pregnancy  are  absent  and  tenderness  is 
marked,  the  condition  is  usually  called  salpingitis;  but  even  then 
mistakes  often  occur,  as  the  menses  may  persist  in  tubal  pregnancy 
and  the  foetal  tumor  may  be  tender.  Only  when  pregnancy  can 
absolutely  be  excluded  is  diagnosis  sure. 

(b)  Tubal  pregnancy,  as  just  explained,  is  rarely  to  be  diag- 
nosed until  the  growth  of  the  foetus  ruptures  the  tube — an  event 
which  usually  occurs  between  the  third  and  the  twelfth  week  of 
pregnancy.^  Sudden  pelvic  pain  with  tenderness,  vomiting,  and 
evidence  of  internal  hemorrhage  {i.e.,  pallor,  fainting,  weak,  rapid 
pulse,  thirst,  air  hunger)  suggest  the  diagnosis,  especially  if  a  tumor 
in  the  tubal  region  can  be  detected  bimanually. 

IV.  Ovaries. — A  prolapsed  ovary  is  often  felt  during  a  vaginal 
examination,  being  recognized  by  its  size,  shape,  and  relation  to  the 
uterus. 

Ovaritis,  enlargement,  and  tenderness  of  one  or  both  ovaries  is 
usually  part  of  tubal  disease  and  not  sharply  to  be  distinguished 
from  it  before  operation.  In  other  cases  it  is  associated  with  cyst  for- 
mation, and  the  cysts  may  be  palpated  bimanually.  Abscess  of  the 
ovary  is  not  commonly  diagnosed,  but  is  met  with  in  operations  for 
pus  tubes. 

Ovarian  Tumors. 

(a)  Small  Tumor. — In  their  earlier  stages  these  growths  pro- 
duce symptoms  only  when  complications  arise,  i.e.,  suppuration  or 
twisting  of  the  pedicle.  Small,  suppurating  cysts  give  practically 
the  same  signs  as  those  of  a  pus  tube,  and  are  recognized  only  at 
operation  or  autopsy. 

Twisted  pedicle  gives  rise  to  symptoms  and  signs  often  indistin- 
guishable from  those  of  perforative  peritonitis  or  intestinal  obstruction. 
Only  the  recognition  of  the  tumor  as  ovarian  can  suggest  that  the  acute 
symptoms  may  be  due  to  twisting  of  its  pedicle. 

(6)  Large  ovarian  tumors  have  been  confused  in  my  experience 
with  pregnancy,  fibroid  of  the  uterus,  ascites,  and  tuberculous  peri- 
tonitis. From  these  we  may  usually  distinguish  an  ovarian  tumor  by 
its  history,  its  origin  from  one  side  of  the  belly,  by  the  shape  of  the 
belly,  the  area  of  percussion  dulness,  and  the  pelvic  examination. 

^  If  disturbances  of  menstruation,  morning  nausea,  changes  in  the  breasts,  and  cyanosis 
of  the  vagina  are  combined  with  an  extra-uterine  tumor  and  an  unusually  slight  uterine 
enlargement,  the  diagnosis  of  tubal  gestation  may  be  suspected  prior  to  rupture. 


422 


PHYSICAL  DIAGNOSIS 


By  the  history  we  should  attempt  to  exclude  disease  of  the  heart, 
kidney,  and  liver,  and  tuberculosis  of  any  organ,  should  inquire 
into  the  position  of  the  tumor  in  the  earlier  stages  of  its  growth, 
and  establish  the  presence  or  absence  of  the  ordinary  signs  of  preg- 
nancy and  of  uterine  hemorrhages  such  as  occur  with  fibroids. 

In  ascites  or  tuberculous  peritonitis  the  flanks  often  bulge  (see 
Fig.  206,  page  348),  whereas  in  ovarian  disease  the  bulging  is  central 
and  greatest  just  below  the  naval  (see  Fig.  230). 


Fig.  230. — Huge  Ovarian  Cyst. 


If  by  the  history  or  by  palpation  and  percussion  we  can  deter- 
mine that  the  tumor  is  fluctuant  and  springs  from  one  side  of  the 
abdomen,  it  is  in  all  probability  ovarian.  High  psoas  abscess  some- 
times presents  identical  signs,  but  is  associated  with  evidence  of 
spinal  tuberculosis  (see  below,  p.  458).  Moderate  ascites  or  tuber- 
culous peritonitis  leaves  an  oval,  resonant  area  about  the  navel, 
which  is  absent  with  large  ovarian  tumors;  but  if  the  amount  of 
free  fluid  is  large,  percussion  and  palpation  may  give  results  identical 
with  those  found  in  ovarian  disease. 


THE  BLADDER,  RECTUM,  AND  GENITAL  ORGANS  423 

Vaginal  examination  may  exclude  fibroid  by  showing  that  the 
uterus  is  not  directly  connected  with  the  tumor  and  by  demonstrating 
with  a  uterine  sound  that  the  uterine  canal  is  not  elongated. 

Solid  tumors  of  the  ovary,  carcinoma,  sarcoma,  or  fibroma  are 
rarely  recognizable  before  operation  and  are  often  mistaken  for  pedun- 
culated uterine  fibroids.     They  are  apt  to  be  associated  with  ascites. 


CHAPTER  XXIII. 
THE  LEGS  AND  FEET. 

The  Legs. 

I.  Hip. 
The  examination  of  the  hip  will  be  discussed  later  (see  page  458). 

II.   Groin. 

In  the  groin  we  look  for  evidences  of : 

1.  Enlarged  or  inflamed  lymphatic  glands  and  scars  of  previous 
inflammation. 

2.  Hernia  and  hydrocele  of  the  cord. 

3.  Psoas  abscess. 
Less  common  are: 

4.  Retained  testis. 

5.  Filarial  lymphatic  varix. 

1.  Inguinal  Glands. — Two  sets  of  inguinal  glands  are  distin- 
guished— one  arranged  along  the  lower  half  of  Poupart's  ligament; 
the  other  lower  down,  around  the  saphenous  opening. 

(a)  The  "Poupart's  group"  are  acutely  enlarged  in  lesions  of 
the  genitals  ("bubo"  of  gonorrhoea/  syphilis,  chancroid)  and  peri- 
neum; chronically  enlarged  in  malignant  disease  of  the  penis,  uterus 
(late),  and  other  genitalia. 

(6)  The  saphenous  group  is  enlarged  in  response  to  lesions  of  the 
thigh,  leg,  and  foot  (cuts,  wounds,  ulcers,  eczema,  etc.). 

(c)  Either  or  both  groups  may  be  enlarged  in  leukaemia,  Hodg- 
kin's  disease  (see  above,  page  30),  infectious  arthritis,  and  various 
obscure  fevers.     In  many  cases  no  cause  for  enlargement  can  be  found. 

2.  Hernia  is  diagnosed  by  the  presence  of  a  soft,  resonant,  fluc- 
tuating, usually  reducible  tumor  with  an  impulse  on  coughing.  Hy- 
drocele of  the  cord  gives  also  an  impulse  on  coughing,  but  usually 
shows  a  distinct  limit  above.  On  pulling  the  cord  the  swelling  moves 
too. 

1  The  bubo  of  gonorrhoea  often  suppurates;  that  of  syphiUs  rarely.     Hence  a  scar  in  the 
in   guinal  region  suggests  an  old  gonorrhoea. 

424 


THE  LEGS  AND  FEET 


425 


3.  Psoas  abscess  (see  Fig.  231)  presents  the  ordinary  signs  of  pus 
and  is  associated  with  vertebral  tuberculosis  (dorsal  or  lumbar) . 

4.  Retained  testis  should  be  suspected  whenever  an  inguinal  tumor 
is  present  and  only  one  testis  is  found  in  the  scrotum. 

5.  Filarial  lymphangiectasis  is  generally  mistaken  for  hernia  and 
operated  on  as  such,  although  it  gives  no  impulse  on  coughing  and 
cannot  be  completely  reduced.     The  history  of  residence  in  the  tropics 
should  always  suggest  an  exami- 
nation of  the   blood   (at  night) 
for  filarise. 

III.    The  Thigh. 

The  records  of  the  Massa- 
chusetts General  Hospital  show 
that  (i)  epiphysitis  and  osteo- 
myelitis (septic  or  tuberculous) 
are  almost  ten  times  as  common 
as  any  other  serious  lesion  of 
the  thigh,  except  fracture.  The 
cases  are  to  be  divided  into 
acute  septic  cases  and  chronic, 
usually  tuberculous,  cases. 

The  acute  septic  cases  begin 
with  severe  pain,  tenderness, 
fever,  chill,  and  leucocytosis. 
Later  an  induration  and  finally 

fluctuation  appear,    and   the   abscess,   if  not  incised,  will  break  ex- 
ternally.    General,  sometimes  fatal,  septicaemia  may  take  place. 

The  chronic  tuberculous  cases  first  consult  the  physician,  as  a 
rule,  for  sinus,  which  proves  when  explored  to  lead  to  dead  bone, 
as  do  most  of  the  sinuses  from  septic  cases. 

The  diagnosis  of  the  acute  cases  depends  chiefly  on  excluding 
arthritis  of  any  type.  Careful  examination  with  testing  of  joint 
motions  will  usually  demonstrate  that  the  pain  and  tenderness  are 
in  the  bone  and  not  in  the  joint.  The  leucocyte  count  is  but 
slightly  elevated  in  most  cases  of  arthritis,  but  is  decidedly  high, 
20,000  or  more,  in  most  cases  of  acute  osteomyelitis.  The  same  is 
true  of  the  temperature.  Monarticular  arthritis — the  only  variety 
likely  to  be  considered  in  such  a  diagnosis — is  rare  in  youth,  when 
most  cases  of  acute  osteomyelitis  and  epiphysitis  occur. 


Fig.  2  1,1. 


-Psoas  Abscess, 
and   Lovett.) 


(Bradford 


426 


PHYSICAL  DIAGNOSIS 


Whether  the  disease  starts  in  the  shaft  of  the  bone  or  in  the 
epiphysis  is  to  be  determined  by  the  seat  of  pain  and  tenderness. 

Tuberculous  cases  can  be  recognized  only  by  the  histological  ex- 
amination. Old  cases  may  be  suspected  by  the  presence  of  a  scar, 
but 

(2)  Multiple  white  scars  should  always  suggest,  though  they  are 
far  from  proving,  syphilis,  for  chronic  ulcer  above  the  knee  is  often 
due  to  gumma. 


Tumors  of  the  Thigh. 

(i)  Sarcoma  of  the  femur  is  the  commonest  and  largest  tumor 
of  the  thigh.     Among  one  hundred  and  thirty- three  tumors  of  the 

thigh  recorded  at  the  Massa- 
chusetts General  Hospital, 
sixty-six  were  sarcoma.  A 
hard,  spindle-shaped  growth 
encircles  the  femur ;  the  lower 
end  is  the  commonest  site, 
but  any  part  of  the  bone  may 
be  affected  (see  Fig.  232). 

(2)  Osteoma,  or  exostosis, 
occurred  eleven  times  in  the 
one  hundred  and  thirty-three 
cases  just  mentioned.  It  is 
much  smaller  and  of  slower 
growth.  The  last  trait  usually 
serves  to  distinguish  it  from 
sarcoma.  X-ray  should  decide. 

(3)  Metastatic  cancer  of  the  upper  half  of  the  femur  may  occur 
after  cancer  of  the  breast,  but  rarely  gives  rise  to  symptoms  unless 
spontaneous  fracture  occurs — an  event  which  always  should  suggest 
cancer.  Epithelioma  of  the  thigh  is  not  very  rare  (twelve  cases  in 
the  one  hundred  and  thirty-three  above  referred  to).  Its  traits  are 
those  of  epithelioma  elsewhere. 

Tuberculosis  of  the  knee  may  simulate  sarcoma  of  the  lower  end  of 
the  femur,  but  sarcoma  grows  more  rapidly.  The  tuberculin  test 
or  an  exploratory  incision  may  be  necessary  to  decide  the  diagnosis. 

(4)  Psoas  abscess  or  hip- joint  abscess  (see  Fig.  231)  may  burrow 
down  so  as  to  point  on  the  thigh.  The  evidence  of  disease  in  the  hip 
or  vertebrae  is  usually  sufficient  to  make  clear  the  diagnosis. 


Fig.  232. — Sarcoma  of  the  Femur. 


thf:  legs  and  feet 


427 


Miscellaneous  Lesions  of  the  Thigh. 

(i)  Phlebitis  with  thrombosis  of  a  vein,  usually  the  saphenous, 
is  a  common  cause  for  swollen  thigh  (and  leg)  with  pain  and  tender- 
ness, especially  over  the  inflamed  vein,  where  a  cordy  induration  can 
often  be  felt.  Typhoid  fever  and  the  puerperal  state  are  the  usual 
causes,  but  it  also  occurs  after  tonsillitis  and  other  infections,  and 
sometimes  without  any  known  cause.  Diagnosis  depends  on  the 
presence  of  these  signs  and  causes 
and  the  absence  of  any  other  de- 
monstrable cause  for  inflammation. 

(2)  Meralgia  parcesthetica  means 
the  presence  of  a  patch  of  anaes- 
thesia, parsesthesia,  or  hyperaes- 
thesia  (tenderness) ,  with  or  without 
pain,  on  the  anterior  and  upper 
surface  of  one  or  both  thighs  (the 
area  of  the  external  cutaneous 
nerve) . 

(3)  Paget's  disease  (osteitis  de- 
formans) presents  usually  its  most 
marked  lesions  in  the  legs  and 
head,  though  most  of  the  other 
bones  are  also  affected.  In  the  leg 
the  most  characteristic  lesions  are 
forward  bowing  of  the  femur  and 
tibia  with  outward  rotation  of  the 
whole  limb  (see  Fig.  233).  The 
:r-ray  shows  marked  thickening  of 
some  areas,  with  thinning  of  p.o.  233.-Paget's  Disease  (Osteitis  De- 
others.  formans).     Note  the  outward  and  forward 

(4)  Intermittent  Claudication  and  bowing  of  legs  and  arms.  (Robin.) 
''Cramps.'' — Insufficient  circula- 
tion through  the  arteries  of  the  legs  may  give  rise  to  sudden  "giving 
way"  of  one  or  both  during  running  or  walking,  the  power  returning 
after  a  short  rest.  In  patients  at  rest  the  frequent  recurrence  of 
painful  cramps  in  the  muscles  may  be  the  only  manifestation  of  the 
disease.  In  other  cases  there  are  various  forms  of  paraesthesia  such 
as  numbness,  prickling,  and  "hot  feet  at  night." 

Obliteration  of  the  dorsalis  pedis  (or  larger  arteries)  by  arterio- 
sclerosis is  often  found,  but  there  is  reason  to  believe  that  local  anaemia, 


428     .  PHYSICAL  DIAGNOSIS 

due  to  vasomotor  disturbances  or  other  causes,  may  produce  similar 
cramps  {e.g.,  those  seen  in  football  players  during  a  hard  run  and  in 
pregnant  women) . 

Paralyses. 

(i)  Paralysis  of  one  leg,  occurring  in  children,  is  usually  due  to 
anterior  poliomyelitis;  in  adults  it  usually  forms  part  of  a  hemiplegia  or 
is  of  hysterical  origin.  Neuritis,  due  to  alcohol,  lead,  arsenic,  or 
diphtheria,  may  affect  one  leg  predominantly,  but  both  are  usually 
involved.  Cerebral  m,onoplegias,  due  to  cortical  lesions  of  the  leg  area, 
are  rare.  Chorea  may  be  associated  with  a  limp,  half -paralyzed  condi- 
tion in  one  leg,  usually  with  some  involvement  of  the  arm  on  the  same 
side,  and  the  characteristic  motions  (see  above,  page  47)  make  the 
diagnosis  clear. 

The  differential  diagnosis  of  the  other  varieties  of  monoplegia  is 
usually  easily  made  with  the  aid  of  a  careful  history  and  a  thorough 
examination  of  the  other  parts  of  the  body. 

(2)  Complete  paralysis  of  both  legs  (paraplegia)  is  commonest  in 
diffuse  or  transverse  myelitis  {e.g.,  in  spinal  tuberculosis  or  metastatic 
cancer  with  pressure  on  the  cord),  in  multiple  sclerosis,  spastic  para- 
plegia (hereditary  or  acquired),  and  in  late  tabes.  Hysteria  also  may 
produce  a  spastic  paraplegia,  though  monoplegia  is  commoner  in  this 
disease. 

(3)  Partial  paralysis  of  both  legs  is  oftenest  due  to  neuritis,  resulting 
from  the  causes  mentioned  above.  The  extensors  of  the  foot  are 
especially  affected  and  toe-drop  results,  so  that  in  walking  "the  entire 
foot  is  slapped  upon  the  ground  like  a  flail"  (Osier). 

Differential  Diagnosis. — (a)  In  diffuse  or  transverse  myelitis, 
whether  or  not  the  trouble  be  due  to  pressure,  there  are  increased 
reflexes,  anaesthesia,  usually  loss  of  control  of  the  sphincters  (involun- 
tary urine  and  faeces) ,  and  often  bed-sores. 

(&)  In  spastic  paraplegia  of  any  type  the  legs  are  stiff  and  the  reflexes 
increased,  but  sensation  and  the  sphincters  are  normal  and  there  is  no 
atrophy  or  bed-sore  formation. 

(c)  In  multiple  sclerosis  there  are  usually  no  disturbances  of  sensa- 
tion or  of  the  sphincters,  and  the  paralysis  is  associated  with  nys- 
tagmus, intention  tremor,  and  slow,  staccato  speech. 

{d)  Tabes  dorsalis  shows  ataxia  but  no  paralysis  until  late  in  its 
course.  The  paralytic  stage  is  preceded  by  a  long  period  characterized 
by  lightning  pains,  bladder  symptoms,  Argyll-Robertson  pupil  (see 
page  16),  and  loss  of  knee-jerks. 


THE  LEGS  AND  FEET 


429 


(e)  Hysteria  may  take  on  almost  any  type  of  paralysis  and  may 
deceive  the  very  elect,  but  as  a  rule  the  other  evidences  of  hysteria 
guide  the  diagnosis. 

.  IV.   The  Knee. 

(a)  Tuberculosis,  atrophic,  hypertrophic,  and  infectious  arthritis, 
and  traumatic  synovitis  are  the  commonest  diseases,  but  will  be 
described  with  other  diseases  of  the  joints  (see  page  456). 


Fig.  234. — Prepatellar  Bursitis  ("Housemaid's  Knee"). 


(6)  Housemaid's  knee  is  a  bursitis  of  the  prepatellar  bursa  (see 
Fig.  234).  Fluctuation,  with  or  without  heat  and  tenderness,  and 
limited  to  the  prepatellar  space,  is  diagnostic. 

(c)  Bow-legs  and  knock-knee  are  so  easy  of  diagnosis  that  I  shall 
simply  mention  them  here. 


430 


PHYSICAL  DIAGNOSIS 


V.   The  Lower  Leg. 

1.  Varicose  veins,  with  their  results  (eczema  and  ulcer),  are  the 
commonest  lesions  of  the  lower  leg.  The  soft,  twisted,  purplish 
eminences  are  easily  recognized.  Hardness  in  such  a  vein  usually 
means  thrombosis.  It  should  be  remembered  that  pregnancy  and 
pelvic  tumors  may  produce  varicose  veins  in  the  legs. 

2.  Chronic  ulcers  of  the  lower  leg,  especially  those  in  front,  are 
usually  due  to  varicose  veins  and  the  resulting  malnutrition  of  the 
tissues.     They   leave    a  brown  scar  after  healing.     Syphilitic   ulcers 


Fig.  235.' — Syphilitic  Periostitis  ("Salve  Shins"). 


usually  leave  a   white  scar;  they  may  occur  in  the  same  situation, 
but  are  more  common  above  the  knee  or  on  the  calf. 

3.  Syphilitic  periostitis  is  common  on  the  shaft  of  the  tibia,  and 
gives  rise  to  pain  (worse  at  night)  with  tenderness  and  some  swelling. 
Later  bony  nodes  are  sometimes  formed,  similar  to  those  already 
pictured  on  the  frontal  bone.  In  doubtful  cases  of  syphilis  in  other 
parts  of  the  body  we  may  sometimes  secure  convincing  evidence  by 
radiography    of    the     tibiae.     Periosteal    thickening,    not    otherwise 


THE  LEGS  AND  FEET 


431 


recognizable,  may  be  thus  brought  to  light  and  may  help  our  diagnosis 
of  a  cardiac  arthritis  or  hepatic  lesion. 

4.  Osteomyelitis  (acute  septic  or  chronic  tuberculous)  often  starts 
on  the  head  of  the  tibia,  with  intense  pain,  tenderness,  fever,  and 
leucocytosis  (if  acute  or  septic) ;  there  results  a  general  septicaemia  or 
a  local  sinus  leading  to  dead  bone. 


Fig.  236. — Angioneurotic  oedema  of  legs. 


5.  Sarcoma  not  infrequently  attacks  the  upper  end  of  the  tibia  or 
fibula,  producing  lesions  similar  to  those  described  in  the  femur. 

6.  (Edema  of  the  legs^  is  oftenest  due  to: 

(a)   Uncompensated    heart    lesions,    primary    or    secondary  from 
lung  disease. 

(&)   Nephritis. 

(c)   Cirrhotic  Liver. 

{d)   Anaemia. 

^  It  is  notable  that  cedema  is  usually  greatest  in  the /row;  of  the  leg  and  in  the  hack  of 
the  thigh. 


432 


PHYSICAL  DIAGNOSIS 


(e)   Neuritis  (alcoholic,  beri-beri,  etc.). 

(/)    Varicose  veins. 

(g)  Obesity,  flat-foot,  and  other  causes  of  deficient  local  circu- 
lation. 

In  some  cases  no  cause  can  be  found  ("angioneurotic"  oedema, 
"essential"    and    "hereditary"    oedema).     Diagnosis   of   the  cause  of 


Fig.  237. — Sporadic  elephantiasis.      (Non-filarial.) 


oedema  depends  on  the  history  and  the  examination  of  the  rest  of 
the  body. 

In  one  leg  oedema  may  be  due  to  thrombosis  of  a  vein  (see  page 
427),  to  pressure  of  tumors  in  the  pelvis  (pregnancy,  etc.),  to  hemi- 
plegia, elephantiasis  (see  Figs.  237  and  238)  or  to  inflammation. 

7.   Tenderness  in   the  lower  legs  frequently  accompanies   oedema 


THE  LEGS  AND  FEET 


433 


from  any  cause.     It  may  also  be  due  to  neuritis  or  trichiniasis,  and, 
of  course,  to  any  local  inflammation. 

The  Feet. 

I.  The  varieties  of  club-foot  are:  (a)  Equinus,  the  heel  drawn 
up.  (.b)  Varus,  the  ankle  bent  outward,  (c)  Valgus,  the  ankle 
bent  inward  and  the  foot  outward,  (d)  Calcaneus,  the  foot  turned 
outward  and  upward. 


Fig.  238. — Elephantiasis. 


The  affection,  which  is  usually  congenital,  occasionally  the  result 
of  contractures  after  paralysis,   presents  no  difficulties  in  diagnosis. 

2.  Flat-foot  is  a  breaking  down  or  weakening  of  the  normal  arch 
of  the  foot.  There  may  or  may  not  be  changes  in  the  sole-print. 
There  are  usually  pain  and  tenderness  near  the  attachment  of  the 
ligaments  and  often  higher  up  on  the  leg. 

3.  Tenosynovitis  of  the  Achilles  tendon  often  produces  pain  in  the 
tendon,  increased  by  use  and  sometimes  associated  with  palpable 
creaking  or  crepitus  over  it. 

28 


434 


PHYSICAL  DIAGNOSIS 


4.  Enlarged  {rachitic)  epiphyses  are  seen  at  the  lower  end  of  the 
tibia  and  fibula  just  above  the  ankle-joint  in  about  forty  per  cent  of 
rachitic  cases.  There  may  also  be  bending  of  the  bones  (see  Fig.  240). 
The  other  signs  of  rickets  in  the  child  make  diagnosis  easy. 

5.  Tuberculosis  is  especially  apt  to  attack  the  ankle  bones  in 
young  persons.  It  is  recognized  by  the  usual  evidences  of  joint 
tuberculosis  (see  below,  page  461). 

6.  Epithelioma  of  the  ankle  has  the  characteristics  of  epithelioma 
elsewhere. 

7.  Erythromelalgia,  or  red  neuralgia  of  the  extremities,  is  common- 
est in  the  feet.     The  toes  (or  fingers)  are  red,  hot,  tender,  and  painful. 


Fig.  239. — Flat-foot.     (Bradford  and  Lovett.) 


In  Raynaud's  disease  the  digits  are  cold  and  painless  or  anaesthetic. 
The  attacks  are  aggravated  by  heat  and  not  (like  those  of  Raynaud's 
disease)  by  cold.  Such  attacks  are  probably  akin  to  the  condition  of 
"hot feet"  often  seen  in  arteriosclerosis  and  myocarditis.  The  patient 
kicks  off  the  bed  clothes  from  his  feet  at  night  on  account  of  the  burn- 
ing sensations  in  them.  Other  evidence  of  insufficient  arterial  blood 
supply  {e.g.,  clubbing,  intermittent  claudication,  cramps,  gangrene) 
may  coexist. 

The  Toes. 

Many  of  the  lesions  already  mentioned  in  the  fingers  are  found  also 
in   the  toes   {e.g.,   atrophic   and  hypertrophic  arthritis,   acromegaly, 


THE  LEGS  AND  FEET  435 

pulmonary  osteoarthropathy,  tuberculous  or  syphilitic  dactylitis, 
tremors,  spasms,  and  choreiform  movements).  Other  lesions,  such 
as  ingrowing  toe-nail,  bunion,  hallux  valgus,  policeman's  heel,  are 
too  purely  local  to  deserve  description  here.  Excluding  these  we 
have  left: 


Fig.  240 — Rachitic  deformity  of  leg  bones. 

1.  Gout,  which  is  especially  prone  to  attack  the  metatarso-phalan- 
geal  joint  of  the  great  toe,  producing  all  the  classical  signs  of 
inflammation. 

2.  Gangrene  is  usually  the  result  of  arteriosclerosis  (see  Fig.  241) 
with  or  without  diabetes  mellitus,  but  may  result  (as  in  the  fingers) 
from  arterial  spasm  or  local  asphyxia  (Raynaud's  disease). 

3.  Perforating  Ulcer. — In  diabetes  and  sometimes  in  tabes  a 
trophic  or  nutritional  ulcer  may  develop  in  the  toe  or  tarsus  as  a 


436 


PHYSICAL  DIAGNOSIS 


result  of  nerve  influences  similar  to  those  which  produce  Charcot's 
joint  or  herpes  zoster  in  the  diseases  just  mentioned.  It  is  called 
"perforating  ulcer"  because  of  its  stubborn  progression  despite  a  plan 
of  treatment  that  checks  ordinary  infectious  abscesses.  Actual  per- 
foration is  not  often  seen. 


Fig.  241 — Arteriosclerotic  gangrene. 


4.  "Tender  toes"  after  typhoid  fever  result  from  an  infectious 
neuritis. 

5.  "Morton's  disease"  (metatarsalgia)  means  pain  in  the  tarsus  at 
a  small  spot  near  the  distal  end  of  one  of  the  three  outer  toes,  always 
associated  with  compression  of  the  foot  by  tight  boots  and  probably 
due  to  pinching  of  the  external  plantar  nerves  between  the  metatarsal 
bones.     It  is  relieved  by  proper  shoes. 


CHAPTER  XXIV. 

THE  BLOOD. 

Examination  of  the  Blood. 

The  essentials  of  blood  examination  as  a  part  of  physical  diagnosis 
are  as  follows :  » 

I.  Hcemoglohin  test  (Tallqvist)  in  all  cases. 

II.  Study  of  a  stained  blood  fihn  in  most  cases. 

III.  Total  leucocyte  count   (Thoma-Zeiss)  in  many  cases. 

IV.  Count  of  red  corpuscles  and  Wtdal  reaction  in  a  few  cases. 

V.  Coagulation  time,  rarely. 

I  will  now  give  a  brief  account  of  each  of  these  methods  and  of  the 
interpretation  of  the  data  obtained  by  them. 

/.   Hce^noglobin. 

(a)  The  Tallqvist  scale  consists  of  ten  strips  of  red-tinted  paper 
corresponding  to  the  tint  of  a  filter  paper  of  standard  quality  when 
saturated  with  blood  containing  ten  per  cent,  twenty  per  cent,  thirty 
per  cent,  etc.,  haemoglobin  up  to  one  hundred  per  cent.  To  perform  the 
test  we  puncture  the  lobe  of  the  ear  with  a  glover's  needle  {7iot  with 
sewing  needle) ,  saturate  a  strip  of  the  filter  paper  which  is  bound  up 
with  the  scale,  in  the  blood  of  the  patient  to  be  examined,  and  compare 
the  tint  of  this  strip  with  the  different  standard  tints  in  the  scale. 
Always  saturate  at  least  half  a  square  inch  of  filter  paper  with  blood 
and  allow  it  to  dry  until  the  gloss  has  disappeared.  Do  not  blot  it,  and 
do  not  delay  in  making  the  comparison  after  the  humid  gloss  has  disap- 
peared. Stand  with  the  light  behind  you  or  at  one  side  of  you;  use 
daylight  always. 

The  test  is  not  accurate  within  ten  degrees,  but  a  degree  of  accuracy 
greater  than  this  is  very  rarely  required  for  any  purpose  of  diagnosis, 
prognosis,  or  treatment.  In  rare  cases,  when  a  more  accurate  reading 
is  needed,  we  may  use  the  instrument  of  Gowers  as  modified  by  Sahli. 

(6)  Sahli' s  instrument  (see  Fig.  242)  must  be  obtained  from  one  of 
the  firms  recommended  by  him,  ^  else  the  standard  solution  is  likely  to 

*  Holtz  or  Biichi  of  Berne. 

437 


438 


PHYSICAL  DIAGNOSIS 


be  inaccurate  in  color.  To  use  the  instrument  we  first  put  a  few  drops 
of  decinormal  HCl  solution  into  the  empty  tube  (Fig.  242 ,  B),  so  as  to 
fill  it  to  the  mark  10;  then  suck  up  blood  with  the  pipette  (Fig.  242,  C), 
until  the  mark  i  is  reached.  Wipe  the  point  of  the  pipette  and  imme- 
diately blow  out  the  blood  into  the  solution  at  the  bottom  of  the  tube 
(B).  Suck  this  mixture  of  blood  and  water  back  into  the  pipette  and 
blow  it  out  again  twice  to  cleanse  the  pipette.  Next  add  water  from 
the  dropper  (D),  a  few  drops  at  a  time,  until  the  tint  of  the  mixture 
of  the  blood  and  water  is  the  same  as  that  of  the  standard  solution, 

when  both  are  looked  at  with  trans- 
mitted light.  After  each  addition 
of  water  close  the  end  of  the  tube 
with  the  thumb  and  invert  it  twice, 
then  scrape  the  thumb  on  the  edge 
of  the  tube  so  as  to  rub  off  any 
moisture  deposited  there  during  the 
process  of  inversion.  As  the  tint 
of  the  mixture  of  blood  and  water 
approaches  that  of  the  standard 
solution,  add  the  water  two  drops 
at  a  time,  and  close  the  eyes  for  a 
few  seconds  between  each  two  at- 
tempts at  reading.  When  the 
colors  in  the  two  tubes  seem  to  be  identical,  read  off  the  figure  cor- 
responding with  the  meniscus  of  the  column  of  fluid  in  the  tube.  The 
resulting  figure  represents  the  percentage  of  haemoglobin. 

(c)  The  Color  Index. — The  data  to  be  obtained  by  these  instru- 
ments stand  for  the  amount  of  the  coloring  matter  in  a  given  unit  of 
blood  when  compared  with  the  amount  in  a  similar  unit  of  normal 
blood.  When  the  haemoglobin  percentage  is  low,  anaemia  is  always 
present,  and  the  degree  of  anaemia  is  measured  by  the  amount  of 
reduction  in  the  haemoglobin  per  cent.  But  the  percentage  of  haemo- 
globin is  not  a  measure  of  the  number  of  corpuscles  present  in  a  given 
unit  of  blood,  for  if  the  corpuscles  are  large  and  contain  each  of  them 
a  relatively  large  amount  of  haemoglobin,  they  may  be  considerably 
diminished  in  number  and  yet  furnish  a  normal  bulk  of  haemoglobin, 
as  tested  by  either  of  the  instruments  described.  Thus  in  pernicious 
anaemia  the  corpuscles  are  often  so  large  that  they  contain  nearly  one- 
third  as  much  again  as  a  normal  corpuscle,  so  that  even  though  their 
number  is  considerably  diminished  they  may  carry  a  normal  amount  of 
haemoglobin.     This  condition  is  known  as  a  "high  color  index."     On 


Fig.  242. — Sahii's  Haemoglobinometer. 
Diluting  tube;  C,  pipette;  D,  dropper 


THE  BLOOD  439 

the  other  hand,  the  number  of  red  corpuscles  may  be  normal,  yet  each 
corpuscle  so  deficient  in  haemoglobin  that  the  haemoglobin  in  a  given 
quantity  of  blood  is  as  low  as  forty  or  fifty  per  cent.  This  state  of 
things  is  often  found  in  chlorosis  or  in  any  form  of  secondary  anaemia 
(see  below,  page  447).  When  the  diminution  in  the  number  of  red 
corpuscles  is  greater  than  the  diminution  of  haemoglobin,  we  say  that 
the  color  index  is  high,  meaning  that  each  corpuscle  carries  more  haemo- 
globin than  normal.  Thus  if  we  have  a  red  count  of  two  millions  and  a 
half  of  red  cells,  and  each  cell  contained  the  normal  amount  of  haemo- 
globin, the  hemoglobin  percentage  would  be  fifty,  representing  a  re- 
duction in  haemoglobin  proportional  to  the  reduction  in  the  red  cells; 
but  if  with  the  same  count  we  had  a  hemoglobin  percentage  of  seventy- 
five,  this  would  mean  that  each  corpuscle  contained  half  as  much  again 
as  compared  with  the  haemoglobin  in  normal  red  cells.  Here  we  should 
say  that  the  color  index  is  1.5.  Five  million  red  cells  and  one  hundred 
per  cent  of  haemoglobin  give  a  color  index  of  i ;  so  do  four  million  red 
cells  with  eighty  per  cent,  of  haemoglobin,  three  million  and  sixty  per 
cent,  two  million  and  forty  per  cent,  and  so  on.  An  example  of  low 
color  index  would  be  four  million  red  cells  with  forty  per  cent  haemo- 
globin, representing  a  color  index  of  0.5;  or  three  million  red  cells  with 
thirty  per  cent  haemoglobin,  representing  again  a  color  index  of  0.5. 

The  diagnostic  significance  of  the  color  index  is  briefly  this:  Any 
diminution  in  hcemoglobin  means  ancemia,  but  a  diminution  in  hcEm,oglo- 
bin  with  a  high  color  index  suggests,  though  it  does  not  prove,  pernicious 
ancemia,  while  a  low  color  index  points  to  chlorosis  or  secondary  ancemia 
of  any  type.  Normal  color  index,  despite  anaemia,  is  most  often  found 
immediately  after  hemorrhage. 

//.  Study  of  the  Stained  Blood  Film. 

To  recognize  the  presence  and  the  degree  of  anaemia  one  needs  only 
the  hcemoglobin  test,  but  to  determine  the  kind  of  anemia,  to  study  the 
leucocytes,  or  to  search  for  parasites  we  need  the  stained  blood  film. 
Two  processes  are  now  to  be  described : 

1.  Preparing  the  film. 

2.  Staining. 

I.  Blood  films  may  be  spread  on  slides  or  on  cover  glasses.  The 
first  method  is  the  easier;  the  second  gives  better  preparations.  To 
prepare  blood  films  on  slides,  dip  two  slides  in  water  and  rub  them 
clean  with  a  towel  or  handkerchief.  Puncture  the  lobe  of  the  ear 
{not  the  finger)   with  a  bayonet  pointed  Glover's  needle  or  surgical 


440 


PHYSICAL  DIAGNOSIS 


needle.  Put  a  drop  of  blood  near  one  end  of  one  slide,  put  the  other 
slide  against  the  drop,  and  rest  it  evenly  upon  the  first,  as  shown  in 
Fig.  243,  so  that  the  drop  will  spread  laterally  across  the  face  of  the 
"spreader."  Next  draw  the  upper  slide  along  horizontally,  so  as  to 
spread  the  drop  over  the  whole  surface  of  the  lower  slide.  The  process 
may  then  be  repeated,  reversing  the  slides  and  using  as  a  "spreader" 
the  one  on  which  the  film  has  already  been  prepared.  Both  slides 
are  then  allowed  to  dry  in  the  air  without  touching  each  other.  This 
method  is  so  simple  that  one  can  usually  succeed  with  it  at  the  first 
attempt,  but  the  corpuscles  are  not  spread  quite  so  evenly  as  in  cover- 
glass  preparations  and  it  is  somewhat  more  difficult  to  get  a  perfect 
stain. 

The  cover-glass  method  requires  a  much  greater  degree  of  cleanliness 
and  manual  dexterity  than  the  slide  method.  Cover  glasses  must  be 
washed  in  water  and  then  thoroughly  polished  with  a  silk  (not  cotton 


{^^^(^j^/af.' 


\^i&ee/  <^e^ 


Fig.  243. — Method  of  Spreading 
Blood  Films. 


Fig.  244.- 


-Proper  Method  of  Holding 
a  Cover  Glass. 


or  linen)  handkerchief.  The  success  of  the  whole  process  depends 
upon  the  thoroughness  of  the  polishing.  Every  part  of  the  glass 
must  be  thoroughly  gone  over,  taking  care  not  to  omit  the  corners. 
This  is  rather  tedious  and  often  drives  us  to  use  slides,  which  can  be 
much  more  quickly  prepared.  With  cover  glasses  we  must  remove 
not  only  all  dirt  and  grease,  but  also  every  speck  of  dust  or  lint 
which  may  settle  upon  them.  The  use  of  silk  as  a  pohsher  reduces 
this  difficulty  to  a  minimum. 

Having  prepared  the  cover  glasses  in  this  way,  the  next  point  is  to 
keep  them  both  clean  and  dry  during  the  process  of  spreading  the 
blood.  We  must  always  hold  them  as  in  Fig.  244,  and  never  touch 
any  part  of  their  surfaces  with  the  fingers.  Any  one  whose  fingers 
tend  to  get  moist  must  handle  the  cover  glasses  with  forceps,  but  most 
of  us  will  always  use  our  fingers,  despite  the  warnings  of  our  Teutonic 


THE  BLOOD  441 

brethren.  Holding  a  cover  glass  as  in  Fig.  244,  touch  the  centre  of  it 
with  the  tip  of  a  drop  of  blood  as  it  is.sues  from  a  puncture,  taking  care 
not  to  touch  the  skin  of  the  ear  itself;  then  drop  this  cover  glass  (blood 
side  downward)  upon  a  second  cover  glass  in  such  a  position  that  their 
corners  do  not  match.  If  the  covers  are  quite  clean  and  free  from 
dust,  the  blood  drop  will  at  once  spread  so  as  to  cover  the  whole  surface 
of  the  glasses.  The  instant  it  stops  spreading,  take  hold  of  the  upper 
cover  glass  by  one  corner  and  slide  it  rapidly  off  without  lifting  it  or 
tilting  it  at  all.  This  needs  some  practice,  and  some  men  never  learn 
it;  hence  the  use  of  slides. 

Films  so  prepared  will  keep  for  a  long  time  without  deteriorating, 
especially  if  the  air  is  excluded. 

2.  Staining. — The  introduction  of  the  Romano wsky  method  of 
staining  (Nocht's,  Ziemann's,  Jenner's,  Leishman's,  Wright's)  enables 
us  to  dispense  with  all  other  blood  stains  and  greatly  shortens  the  time 
of  the  process.  Wright's  stain  is  identical  with  Leishman's  except  in 
the  method  of  preparation,  which  Wright  has  considerably  simplified, 
and  as  either  of  these  mixtures  can  be  obtained  ready  made  of  any  of 
the  larger  dealers  in  physicians'  supplies,  I  shall  not  describe  the 
method  of  making  it.  Reliable  stains  can  always  be  obtained  from 
the  Massachusetts  General  Hospital  in  Boston.  An  ounce  bottle  will 
stain  hundreds  of  specimens. 

To  stain  a  cover-glass  film,  grasp  it  with  Cornets' s  forceps,  rest  the 
forceps  on  the  sink  so  that  the  film  side  is  upward  and  is  approximately 
horizontal.  Draw  a  little  of  Wright's  or  Leishman's  stain  into  a 
clean  medicine-dropper  and  squeeze  out  upon  the  film  enough  to 
flood  its  surface. 

(a)  Allow  the  stain  to  act  for  one  minute;  during  this  time  the 
methylic  alcohol  contained  in  it  fixes  the  film  upon  the  cover  glass. 

(6)  Next  add  distilled  water  from  a  clean  medicine-dropper  until 
a  greenish  metallic  lustre  appears  like  a  scum  upon  the  surface  of  the 
stain.  Usually  about  six  or  eight  drops  of  water  are  needed  if  we  are 
using  a  seven-eighths-inch  cover  glass.  The  stain,  so  diluted  with 
water,  should  remain  upon  the  cover  glass  about  two  'minutes.  The 
exact  time  does  not  matter. 

(c)  Next  wash  off  the  stain  with  water  cautiously  and  let  the  film 
remain  in  clean  water  for  about  a  minute  more  or  until  it  takes  on  a 
light  pink  color.  Dry  gently  with  blotting  paper  and  mount  in 
Canada  balsam. 

This  whole  process  can  be  completed  inside  of  five  minutes,  and  I 
know  of  no  other  staining  method  at  once  so  rapid,  so  reliable,  and  so 


442 


PHYSICAL  DIAGNOSIS 


widely  applicable.  It  brings  out  all  the  minutiae  of  the  red  corpuscles, 
leucocytes,  and  blood  parasites,  and  for  clinical  work  no  other  stain  is 
needed. 

Appearance  of  Films  so  Stained. — i.  The  normal  red  corpuscles 
appear  as  round  discs  with  pale  centres.  Their  color  depends  upon 
the  length  of  time  that  we  continue  the  washing  with  clear  water  after 
the  staining  mixture  has  been  poured  off,  and  varies  from  brown 
through  pink  to  golden  yellow. 

(a)  Poikilocytosis  means  the  appearance  in  the  blood  of  red  cells 
variously  deformed,  sausage  shaped,  battledore  shaped,  oblong,  pear 
shaped,  etc.  It  is  always  associated  with  abnormalities  in  the  size  of 
the  corpuscles,  so  that  dwarf  forms  and  giant  forms  appear. 

{h)  Polychromasia  (or  polychromatophilia)  refers  to  abnormal 
staining  reactions  in  the  red  corpuscles,  whereby  isolated  individuals 
take  on  a  brownish  or  purplish  tint,  sharply  contrasted  with  the  pink 
or  yellow  of  the  corpuscles  around.     If  this  brownish  or  purplish  tint 

occurs  in  all  the  corpuscles,  it  has 
no  pathological  significance,  but 
merely  means  that  the  staining  has 
been  incorrectly  performed. 

(c)  "Stippling"  refers  to  fine, 
dark-blue  dots  scattered  over  the 
pink  surface  of  a  red  corpuscle,  as 
if  a  charge  of  fine  shot  had  been 
fired  into  it. 

All  the  abnormalities  just  de- 
scribed are  to  be  found  in  any  of 
the  types  of  severe  anaemia,  whether 
primary  or  secondary,  but  st^ppling 
may  also  be  found  without  ancemia 
in  some  cases  of  lead  poisoning,  and 
is  therefore  useful  as  a  confirmatory 
sign  in  cases  of  this  disease. 

Nucleated  red  corpuscles  are  divided  into  two  main  varieties:  (i) 
normoblasts,  which  are  of  the  size  of  normal  corpuscles;  and  (2)  mega- 
loblasts,  which  are  larger  than  normal  corpuscles  (see  Fig.  245).  The 
nucleus  of  the  normoblast  is  generally  small  and  deeply  stained,  navy 
blue.  In  the  megaloblast  the  nucleus  may  have  the  same  character- 
istics or  may  be  much  larger  and  paler,  with  a  distinct  intranuclear  net- 
work. The  protoplasm  of  both  varieties  is  often  discolored,  murky, 
gray,  or  even  blue,  and  sometimes  stippled,  so  that  by  beginners  the 


Fig.  245. — Nucleated  Red  Cells,  m,  m, 
Megaloblasts;  n,  normoblast;  s,  stippled 
ceU. 


THE  BLOOD 


443 


cell  may  be  mistaken  for  a  leucocyte.  The  mistake  may  be  avoided, 
however,  after  some  experience.  In  the  protoplasm  of  nucleated  cells 
there  are  often  concentric  rings  like  the  layers  in  an  oyster  shell,  and 
their  outline  is  usually  more  irregular  than  that  of  any  leucocyte. 
Further  points  of  differentiation  must  be  learned  by  practice. 

2.  Leucocytes. — In  normal  blood  four  main  varieties  may  be  dis- 
tinguished : 

(a)  Polynuclears  or  polymorphonuclear  neutrophiles. 

(6)   Lymphocytes  (large  and  small). 

(c)    Eosinophiles. 

{d)   Mast  cells. 

(a)  Polynuclears. — The  deeply  stained,  markedly  contorted  nucleus 
assumes  a  great  variety  of  shapes  in  different  cells,  and  is  surrounded 
by  a  pinkish  protoplasm  studded  with  spots  or  granules  just  large 


Fig.  246. — a,  Leucocytosis  (40,000);  sixteen  polynuclears  in  a  field,  h.  Lymphatic  leu- 
kaemia, p,  Polynuclear;  m,  megaloblast;  e,  eosinophile.  Twenty-one  lymphocytes 
in  this  field. 


enough  to  be  distinguished  under  the  oil  immersion  and  slightly  deeper 
in  tint  than  the  protoplasm  around  them.  These  cells  make  up  about 
two-thirds  {fifty  to  seventy  per  cent)  of  all  the  leucocytes  present  in  the 
blood  (see  Fig.  246,  a). 

(6)  Lymphocytes. — The  smallest  variety  is  about  the  size  of  a  red 
cell,  and  consists  of  a  round  nucleus  stained  deep  blue  and  surrounded 
by  a  very  narrow  rim  of  pale,  bluish-green  protoplasm.  In  the  larger 
forms  the  nucleus  occupies  much  less  space  relatively,  is  often  less 
deeply  stained,  and  may  be  indented.     The  latter  variety  is  sometimes 


444  PHYSICAL  DIAGNOSIS 

burdened  with  the  useless  name  of  "  transitional  cell,"  a  term  which  in 
my  opinion  should  be  given  up,  since  all  lymphocytes  are  transitional. 
In  the  protoplasm  of  the  larger  varieties  of  lymphocyte  one  often  sees 
a  sprinkling  of  fine  pink  granules.  From  twenty-five  to  thirty- five  per 
cent  (or  about  one-third)  of  all  leucocytes  belong  to  the  lymphocyte 
group — classing  all  sizes  together  (see  Fig.  246,  h) . 

(c)  Eosinophiles. — The  nucleus  is  irregularly  contorted  and  attracts 
very  little  notice,  owing  to  the  very  brilliant  pink  color  and  relatively 
large  size  of  the  granules  in  which  it  is  immersed.  The  outline  of  the 
cell  is  more  irregular  than  that  of  any  other  leucocyte,  and  its  granules 
often  become  broken  away  and  scattered  in  the  technique  of  spreading 
the  blood.  The  eosinophiles  make  up  approximately  one  per  cent  of  the 
leucocytes  of  normal  blood. 

{d)  Mast  Cells. — The  shape  of  the  nucleus  can  rarely  be  made  out, 
and  the  main  characteristic  of  the  cell  is  the  presence  of  large  dark 
granules,  stained  bluish  black  or  plum  color,  and  arranged  most  thickly 
about  the  margin  of  the  cell.  Mast  cells  are  very  scanty  in  normal 
blood  and  make  up  not  more  than  one-half  of  one  per  cent  of  the 
leucocytes. 

Other  varieties  of  leucocytes  which  appear  in  the  blood  only  in 
disease  will  be  mentioned  later. 

3.  Blood  Plates. — In  the  normal  blood  film,  stained  as  directed 
above,  one  finds,  beside  the  red  corpuscles  and  the  different  varieties 
of  leucocytes,  a  varying  number  of  bodies,  usually  about  one-third  the 
diameter  of  a  red  corpuscle,  irregularly  oval  in  shape,  staining  dark  red 
or  blue  and  tending  to  cohere  in  bunches.  Occasionally  larger  forms 
occur,  and  in  these  a  vague  network  and  some  hints  of  a  nucleus  may 
be  traced. 

These  bodies  which  are  probably  derived  from  one  or  more  species 
of  leucocytes  have  at  present  no  considerable  importance  in  medicine, 
although  they  not  infrequently  lead  to  mistakes,  because,  when  lying 
on  top  of  a  red  corpuscle,  they  bear  a  slight  resemblance  to  a  malarial 
parasite.  They  are  usually  increased  in  secondary  anaemia  and  dimin- 
ished in  pernicious  anaemia. 

The  Differential  Count  of  Leucocytes. 

A  film  stained  as  above  directed  is  moved  past  the  objective  of 
the  microscope  either  with  a  mechanical  stage  or  with  the  fingers,  and 
every  leucocyte  seen  is  classified  under  one  of  the  heads  just  described 
until  from  200-400  leucocytes  have  been  thus  differentiated.  The 
percentages  are  then  reckoned  out. 


THE  BLOOD 


445 


The  points  most  often  looked  for  are: 

1.  Increase  in  the  per  cent  of  polynuclears. 

2.  Increase  of  eosinophiles. 

3.  Increase  of  lymphocytes. 

4.  Presence  of  myelocytes  and  other  abnormal  forms  (see  below). 

5.  Changes  in  the  red  cells  noted  simultaneously. 

///.   Counting  the  White  Corpuscles. 

The  instrument  used  all  over  the  world  at  the  present  day  is  the 
pipette  of  Thoma-Zeiss,  in  which  the  blood  is  diluted  either  ten  or 
twenty  times.  The  diluting  solution  is  one-half  of  one  per  cent  glacial 
acetic  acid  in  water.  This  diluting  solution  often  accumulates  spores 
and  becomes  cloudy.  As  soon 
as  this  happens  a  fresh  bottle 
should  be  prepared.  After  a 
rather  deep  puncture  blood  is 
sucked  up  to  the  mark  point 
.5  on  the  pipette,  which  is 
then  immersed  in  the  diluting 
solution  and  suction  exerted 
until  the  mixture  is  drawn  up 
to  the  point  marked  11.  This 
gives  a  dilution  of  one  to 
twenty.  By  drawing  blood 
up  to  the  point  marked  i, 
instead  of  to  the  point  marked 
.5,  we  obtain  a  dilution  of  one 
to  ten.  After  this  the  ends 
of  the  pipette  can  be  closed 
with  a  rubber  band,  and  the 
blood,  so  shut  in,  can  be  kept  or  transported  without  loss  or  change. 

When  we  are  ready  to  make  the  count,  the  rubber  band  is  removed 
and  the  pipette  rolled  in  the  fingers  rapidly  back  and  forth  for  about 
one  minute,  to  mix  up  the  contents  of  the  bulb  thoroughly  and  evenly. 
Next  blow  out  three  drops,  in  order  to  get  rid  of  the  pure  diluting 
solution  which  is  in  the  shank  of  the  pipette.  Then  put  upon  the 
circular  disc  of  the  counting  chamber  a  drop  of  the  mixture  from  the 
bulb  of  the  pipette.  This  drop  must  be  of  such  a  size  that  when  the 
cover  glass  (see  Fig.  248  B)  is  let  down  upon  it^  the  drop  will  cover  at 

^  To  avoid  air  bubbles  lower  the  cover  glass  with  aid  of  a  needle  as  in  mounting  micro- 
scopic specimens.  This  must  be  done  as  quickly  as  possible  after  the  drop  has  been 
adjusted  on  the  counting  disc. 


Fig. 


247. — Indicating  an  Order  in  which  the 
Squares  may  be  Counted. 


446  PHYSICAL  DIAGNOSIS 

least  nine-tenths  of  the  circular  disc  and  not  spill  into  the  moat  around 
it.  The  size  of  this  drop  can  only  be  learned  by  practice.  After 
about  five  minutes  the  leucocytes  will  have  settled  upon  the  ruled 
space  which  occupies  the  centre  of  the  floor  of  the  counting  chamber, 
and  the  count  can  then  be  begun,  using  preferably  a  No.  5  objective 
of  Leitz  or  a  DD  of  Zeiss.  The  whole  ruled  space  should  be  counted, 
and  after  a  little  practice  this  takes  not  more  than  five  minutes.  I 
usually  begin  my  count  in  the  left  upper  corner  of  the  ruled  space  and 
proceed  in  the  direction  indicated  by  the  serpentine  arrow  in  Fig.  247. 
In  normal  blood  one  finds  from  thirty  to  fifty  leucocytes  in  the  whole 
ruled  space.  The  number  of  leucocytes  per  cubic  millimetre  is 
obtained  by  multiplying  this  figure  by  200.     Thus  if  the  number  of 


I  ^^'^^^^^ J 

Fig.  248. — Thoma-Zeiss  Counting  Slide.     A,  Ruled  disc;  B,  cover-glass;  C,  moat. 

leucocytes  counted  is  35,  the  number  in  a  cubic  millimetre  of  blood  is 
35X200  =  7,000.  If  great  accuracy  is  needed,  a  second  count  with  a 
fresh  drop  should  be  made  and  the  average  of  the  two  taken;  but  in 
ordinary  clinical  work  this  does  not  seem  to  me  necessary,  for  the 
amount  of  error,  although  considerable,  is  not  such  as  to  affect  our 
diagnostic  inferences. 

IV.   Counting  the  Red  Corpuscles. 

Perhaps  once  in  every  twenty-five  or  fifty  cases  that  one  sees  it  is 
well  to  know  the  number  of  red  corpuscles.  They  can  then  be  counted 
with  the  Thoma-Zeiss  pipette  which  is  made  for  the  purpose,  and  so 
arranged  that  the  blood  may  be  diluted  one  to  two  hundred.  The 
technique  is  exactly  that  described  in  the  last  section,  except  that  we 
need  less  blood  and  use  a  different  diluting  solution.  I  am  accustomed 
to  use  a  mixture  suggested  by  Gowers,  made  up  as  follows: 

Sodium  sulphate gr.  cxii. 

Dilute  acetic  acid oi- 

Water oiv. 

Blood  is  sucked  up  to  the  mark  0.5  and  then  Gowers'  solution  to 
the  mark  loi.  After  the  drop  has  been  adjusted  in  the  counting 
chamber  and  the  corpuscles  have  settled  upon  the  ruled  space,  we 
usually  count  a  field  of  twenty-five  small  squares  at  each  of  the  four 
corners  of  the  whole  ruled  space.  The  figure  so  obtained  is  multiplied 
by  8,000.     The  result  is  the  number  of  corpuscles  per  cubic  millimetre. 


THE  BLOOD  447 

Interpretation  of  the  Results  so  Obtained. 
I.  Secondary  Ancemia. 

The  haemoglobin  is  usually  reduced  more  than  the  count  of  red 
corpuscles,  giving  a  low  color  index.  In  mild  cases  the  haemoglobin 
may  fall  as  low  as  forty  per  cent  before  the  red  corpuscles  show  any 
considerable  diminution.  In  severe  cases  the  red  cells  fall  to  3,000,000, 
2,000,000,  and  occasionally  even  to  1,000,000  or  below  it;  but  the 
haemoglobin  usually  suffers  even  more  severely. 

The  leucocytes  may  be  normal,  increased,  or  diminished,  depending 
on  the  cause  of  the  anaemia.  Thus  in  anaemia  due  to  chronic  suppura- 
tive hip-disease  the  leucocytes  are  often  increased  to  20,000  or  30,000, 
while  in  malarial  anaemia  the  leucocytes  are  often  subnormal.  There 
are  no  characteristic  changes  in  the  differential  count,  which  varies 
with  the  underlying  disease. 

The  changes  seen  in  the  red  cells  in  the  stained  blood  film  are 
briefly:  Poikilocytosis,  abnormal  staining  of  the  red  corpuscles,  and 
the  presence  of  nuclei  either  in  normal-sized  corpuscles  (normoblasts) 
or  in  giant  corpuscles  (megaloblasts) .  The  degree  of  poikilocytosis 
and  abnormal  staining  reaction  is  proportional  to  the  severity  of  the 
anaemia.  In  mild  cases  we  find  only  normoblasts,  and  those  only  after 
a  long  search;  in  severe  cases  we  may  find  megaloblasts  as  well,  but 
almost  invariably  these  cells  are  fewer  than  the  normoblasts. 

The  commonest  causes  for  secondary  or  symptomatic  anemia  are 
as  follows : 

(a)  Hemorrhage — gastric,  hemorrhoidal,  traumatic,  puerperal,  etc. 

(6)  Malaria,  more  rarely  sepsis  or  other  infections. 

(c)  Malignant  disease. 

(d)  Chronic  suppurations. 

(e)  Chronic  glomerulo-nephritis. 
(/)  Cirrhosis  of  the  liver. 

(g)  Poisons,  especially  lead. 
(h)   Chronic  dysentery. 
(i)   Intestinal  parasites. 

It  is  important  to  remember  that  insufficient  food  or  even  starva- 
tion does  not  produce  anaemia,  and  so  far  as  we  know  no  form  of  bad 
hygiene  has  any  notable  effect  upon  the  blood.  Persons  may  grow 
very  pale  under  bad  hygienic  conditions,  but  their  blood  is  usually  not 
affected  unless  one  of  the  diseased  conditions  mentioned  above  is 
present. 


448  PHYSICAL  DIAGNOSIS 

2.   Chlorosis. 

The  blood  is  practically  identical  with  that  just  described,  though 
the  color  index  is  sometimes  lower,  poikilocytosis  less  marked,  and 
nucleated  red  cells  fewer.  The  pallor  of  the  centres  of  the  cells 
("achromia")  is  often  very  marked.  The  leucocytes  are  generally 
normal  and  the  differential  count  practically  so,  although  the  percent- 
age of  polynuclear  cells  is  often  low  with  a  corresponding  relative 
increase  of  lymphocytes. 

3.  Pernicious  Ancemia. 

The  number  of  red  cells  is  usually  below  2,000,000  when  the  case 
is  first  seen.  The  color  index  is  high  and  the  leucocyte  count  sub- 
normal. The  stained  specimen  shows  very  marked  deformities  and 
abnormal  staining  reactions  in  the  red  cells,  with  a  tendency  to  the 
predominance  of  large  forms.  Many  of  the  latter  contain  nuclei 
("megaloblasts"),  and  a  smaller  number  of  normal-sized  cells  also 
contain  nuclei  ("normoblasts"). 

The  polynuclears  are  relatively  diminished,  with  a  corresponding 
relative  increase  in  the  lymphocytes. 

In  the  remissions  which  form  so  important  a  feature  of  the  course 
of  pernicious  anaemia,  the  blood  is  generally  transformed  until  it  is 
almost  or  quite  normal.  In  the  subsequent  fall  it  may  take  on  all  the 
features  of  secondary  ansemia  or  chlorosis,  and  lead  to  unavoidable 
errors  in  diagnosis  and  prognosis.  Fortunately  cases  are  rarely  seen 
for  the  first  time  at  this  (non-characteristic)  stage. 

Interpretation  of  the  Results  of  the  Leucocyte  Count  and 
Differential  Count. 

By  combining  the  facts  obtained  by  the  total  white  count  and  the 
differential  count,  we  can  estimate  the  number  of  each  variety  of 
leucocyte  contained  in  a  cubic  millimetre  of  blood.  Thus  with  10,000 
white  corpuscles,  70  per  cent  of  which  are  polynuclear  (as  seen  in  the 
stained  film),  we  have  7,000  polynuclear  cells  per  cubic  millimetre, 
which  may  be  considered  the  upper  normal  limit.  Any  number  greater 
than  this  should  be  considered  as  a  leucocytosis.  In  a  similar  way 
we  can  say  that  any  number  greater  than  3,500  is  above  the  normal 
limit  for  lymphocytes  and  constitutes  a  lymphocytosis,  while  eosino- 
philia  is  present  whenever  the  number  of  eosinophiles  is  more  than  400 
per  cubic  millimetre.     It  is  much  better  to  use  these  absolute  numbers 


THE  BLOOD  449 

than  to  rely  upon  percentages.  If  we  say,  for  example,  that  3  per  cent 
of  eosinophiles  is  within  normal  limits,  we  shall  make  an  error  now  and 
then  in  cases  of  myelogenous  leukaemia,  in  which,  with  a  total  count  of 
500,000  leucocytes,  3  per  cent  of  eosinophiles  would  amount  to  a  total 
of  15,000  per  cubic  millimetre,  or  nearly  thirty  times  the  normal 
number.  Errors  are  also  common  in  the  opposite  direction.  For 
example,  in  typhoid,  with  a  total  leucocyte  count  of  3,000,  the  lympho- 
cytes may  reach  60  per  cent  and  yet  be  well  within  the  normal  limits, 
for  60  per  cent  of  3, 000  is  only  1,800.  In  this  case  the  apparent  lymph- 
ocytosis is  due  to  an  absolute  decrease  in  polynuclear  cells. 

For  the  reasons  here  given  it  seems  to  me  best  to  use  the  following 
definitions: 

1.  Leucocytosis  is  an  increase  in  the  polynuclear  cells  beyond  the 
normal — 7,000. 

2.  Lymphocytosis  is  an  increase  of  lymphocytes  beyond  the  normal 
upper  limit — 3,500. 

3.  Eosmophilia  is  an  increase  of  eosinophiles  beyond  the  normal 
upper  limit — 500  per  cubic  millimetre. 

Occurrence  of  Leucocytosis. 

Leucocytosis,  like  fever,  occurs  in  a  great  variety  of  conditions,  of 
which  the  following  are  the  most  important : 

1.  In  infectious  diseases — except  typhoid,  typhus,  malaria,  uncom- 
plicated tuberculosis,  measles,  smallpox  (prior  to  the  pustular  stage), 
mumps,  German  measles,  and  influenza  (most  cases). 

2.  In  a  variety  of  toxcemic  conditions,  such  as  uraemia,  hepatic 
toxaemia,  diabetic  coma,  rickets,  and  poisoning  by  illuminating  gas. 

3.  In  a  minority  of  cases  of  malignant  disease,  especially  sarcoma. 

4.  After  violent  musctdar  exertion,  including  parturition,  and  after 
cold  baths  or  massage. 

There  is  in  all  probability  no  constant  leucocytosis  in  pregnancy 
or  during  digestion. 

Leucocytosis  is  most  often  of  value  in  the  differential  diagnosis 
between  typhoid  fever  or  malaria  on  the  one  hand,  and  pyogenic 
infections  (meningitis,  appendicitis,  sepsis,  pneumonia)  on  the  other. 
A  leucocyte-chart  is  often  of  value  in  judging  whether  a  local  suppura- 
tive process,  such  as  appendicitis,  is  advancing  or  receding,  or  whether 
pus-pocketing  has  taken  place.  By  a  leucocyte-chart  is  meant 
series  of  leucocyte  counts  at  short  intervals — twelve,  twenty-four,  or 
forty-eight  hours.      When  taken  in  connection  with  the  other  clinical  data, 

29 


450  PHYSICAL  DIAGNOSIS 

a  leucocyte  chart  is  often  of  the  greatest  value,  especially  in  follow- 
ing the  course  of  any  disease;  to  a  less  extent  in  diagnosis.  Sondern 
{Med.  Record,  N.  Y.,  March  25,  1905)  considers  that  the  higher  the 
per  cent  of  polynuclears,  the  severer  the  infection,  while  the  body's 
resistance  is  mirrored  in  the  height  of  the  total  leucocyte  count.  By 
noting  both  these  facts,  therefore,  we  have  a  prognostic  guide  of  some 
importance.  Most  subsequent  observations  have  tended  to  verify 
Sondern' s  theory.  In  internal  medicine  leucocyte  counts  are  especially 
useful  in  febrile  conditions,  in  the  great  majority  of  which  they  assist  the 
diagnosis. 

Certain  exceptions  to  the  rules  above  given  must  be  remembered: 

1.  Quiescent,  thickly  encapsulated  collections  of  pus,  in  which  the 
bacteria  have  died  or  lost  their  virulence,  usually  produce  no  leucocyto- 
sis.  In  this  group  come  some  of  the  abscesses  of  the  liver  or  about  the 
kidney,  and  a  few  cases  of  appendicitis. 

2.  The  most  virulent  and  overwhelming  infections  are  apt  not  to  be 
accompanied  by  leucocytosis.  Thus,  for  example,  the  most  virulent 
cases  of  pneumonia,  diphtheria,  or  general  peritonitis  often  run  their 
course  without  leucocytosis. 

Lymphocytosis. 

Only  in  three  diseases  does  well-marked  lymphocytosis  often  occur : 
I.  Lymphatic  leukaemia.  2.  Whooping-cough  and  its  complications 
(many  cases) .  3 .  Acute  sepsis  with  or  without  glandular  enlargement 
may  produce  a  lymphocytosis  which,  but  for  the  etiological  factor, 
would  be  alarmingly  like  lymphoid  leukaemia. 

Occasionally  lymphocytosis  occurs  in  rickets,  hereditary  syphilis, 
and  anything  that  produces  debility  in  children.  Lymphocytosis  is 
of  value  chiefly  in  the  differentiation  of  lymphatic  leukaemia  from 
other  causes  of  glandular  enlargement. 

Eosinophilia. 

The  eosinophiles  are  increased  chiefly  in: 

1.  Bronchial  asthma. 

2.  Chronic  skin  diseases. 

3.  Diseases  due  to  animal  parasites  (trichiniasis,  uncinariasis, 
filariasis,  hydatid  disease,  Bilharzia  disease,  trypanosomiasis,  and  with 
most  of  the  intestinal  worms). 

4.  Myelogenous  leukaemia. 

There  seems  to  be  also  some  vague  connection  between  eosinophilia 


THE  BLOOD 


451 


and  diseases  of  the  female  genital  tract  (except  cancer  and  fibromyoma 
of  the  uterus) . 

Leukemia. 

Two  forms  are  distinguished,  though  the  distinction  is  chiefly  a 
clinical  one:  (a)  Myeloid  and  (b)  lymphoid. 

I.  Myeloid  Leukcemia. 

The  leucocytes  are  usually  about  250,000  per  cubic  millimetre  when 
the  case  is  first  seen,  but  often  run  much  higher,  and  sometimes  lower. 
There  is  no  anaemia  in  the  earliest  stages;  later  moderate  secondary 
anaemia  develops. 

The  differential  count  shows  an  extraordinary  variety  of  types, 
ncluding  many  not  seen  in  normal  blood  (see  Fig.  249) .  The  majority 
of  the  leucocytes  are  polynuclears, 
but  many  of  these  are  atypical  in 
size  or  in  the  shape  of  their  nucleus. 
From  20  to  40  per  cent  of  the  leuco- 
cytes are  myelocytes  (or  mononu- 
clear neutrophiles) ,  the  "infantile" 
form  of  the  polynuclear  cell.  Lym-- 
phocytes  are  absolutely  normal  or 
increased,  but  their  percentage  is 
low,  on  account  of  the  greater  in- 
crease of  the  other  forms.  Eosino- 
philes  are  absolutely  much  in- 
creased, though  the  percentage  is 
not  much  above  normal.  Mast  cells 
are  more  numerous  than  in  any 
other  disease  (i  to  12  per  cent,  out 
of  an  enormous  total  increase). 
Normoblasts  are  usually  very  numerous ;  megaloblasts  scanty. 

Under  the  influence  of  intercurrent  infections  or  after  x-tslj  treat- 
ment the  blood  may  return  to  normal. 

2.  Lymphoid  Leukcemia. 

The  total  increase  of  leucocytes  is  usually  much  less  than  in  the 
other  type  of  leukaemia — 40,000  or  80,000 — or  less  in  average  cases. 
The  differential  count  shows  an  overwhelming  proportion  of  lymph- 
ocytes— 90  to  99.9  per  cent  as  a  rule.  In  the  acute  forms  of  the  disease 
the  large  lymphocytes  predominate;  in  chronic  cases  the  small  forms. 


Fig.  249. — Myelogenous  Leukaemia. 
m,  Myelocytes;  p,  polynuclear;  b,  mast 
cell;  n,   normoblast. 


452  PHYSICAL  DIAGNOSIS 

The  blood-film  is  monotonous  in  contrast  with  the  wonderful 
variety  seen  in  myelogenous  leukemia  (see  Fig.  246,  h). 

V.   The  Widal  Reaction. 

(a)  Technique.  Among  the  numerous  agglutinative  reactions 
between  the  serum  of  a  given  disease  and  the  micro-organism  producing 
that  disease,  only  one  has  yet  attained  wide  use  in  clinical  medicine, 
viz.,  the  so-called  Widal  reaction  in  typhoid  fever. 

There  are  many  ways  of  performing  this  reaction,  but  in  my 
opinion  the  following  is  the  best : 

Measure  out  in  two  small  test  tubes  ten  drops  and  fifty  drops 
respectively  of  a  highly  motile  twelve-  to  twenty-four-hour  bouillon 
culture  of  typhoid  bacilli,  in  which  the  bacilli  have  no  tendency  to 
adhere  spontaneously  to  each  other.  Carry  these  tubes  and  a  micro- 
scope to  the  bedside,  puncture  the  patient's  ear  as  usual,  and  draw  a 
little  blood  into  a  medicine-dropper  of  the  same  size  as  that  used  in 
measuring  out  the  typhoid  culture.  Expel  one  drop  of  blood  into  each 
of  the  tubes  containing  typhoid  culture,  and  examine  a  drop  of  each 
mixture  between  a  slide  and  cover  glass  with  a  high-power  dry  lens. 
If  within  fifteen  minutes  clumping  has  taken  place  in  the  1:10  mixture, 
or  if  within  one  hour  clumping  has  taken  place  in  the  1:50  mixture, 
the  reaction  may  be  considered  positive.  By  clumping  I  mean  an 
agglutination  of  the  bacilli  into  large  groups  and  the  complete  or  nearly 
complete  cessation  of  motility. 

If  it  is  inconvenient  to  carry  the  culture  and  the  microscope  to  the 
bedside,  ten  or  twenty  drops  of  blood  may  be  milked  out  of  the  ear 
and  collected  in  a  test  tube  (a  three-inch  test  tube  of  small  calibre  is 
best).  After  clotting  has  taken  place,  if  the  edges  of  the  clot  are 
separated  from  the  glass  with  a  needle  or  a  wire,  a  few  drops  of  serum 
will  exude,  and  this  serum  can  be  mixed  with  the  bouillon  culture  in 
the  manner  already  described. 

Less  reliable,  in  my  opinion,  is  the  use  of  blood  dried  upon  glass  or 
glazed  paper  in  large  drops  and  subsequently  dissolved  in  the  culture 
itself. 

(&)  Interpretation.  A  positive  reaction  occurs  at  some  period  in 
the  course  of  ninety-five  per  cent  of  all  cases  of  typhoid  fever,  but  the 
proportion  of  cases  in  which  the  reaction  occurs  early  enough  to  be  of 
diagnostic  value  varies  greatly  in  different  epidemics.  In  most 
epidemics  about  two-thirds  of  the  cases  show  a  positive  Widal  reaction 
by  the  time  the  patient  is  sick  enough  to  consult  a  physician.  The 
reaction  may  be  absent  one  day  and  present  on  the  next,  and  varies 


Cabot — Physical  Diagnosis. 


PLATE  IV. 


Fig.   I. — Young  Tertian  Parasites.     (Stained  with  Wright's  modification  of  Leishman's 

stain.) 


Fig.  2. — Mature  Tertian  Parasites.     (Eosin  and  methylene  blue.) 


Fig.  3. — Segmenting  Tertian  Parasites.     (Eosin  and  methylene  blue.) 


THE  BLOOD 


453 


greatly  in  intensity  in  different  cases  and  at  different  times  with  the 
same  case. 

The  Wassermann  Reaction. 

I  shall  attempt  no  description  of  the  technique  of  this  most  valuable 
and  important  test,  because  its  performance  is  so  difficult  and  delicate 
that  only  one  who  is  constantly  doing  it  is  reliable.  A  positive  reaction 
done  by  a  reliable  expert  is  very  important  evidence  of  syphilis. 
Negative  reactions  do  not  exclude  syphilis.  The  reaction  is  of  especial 
value  in  cases  of  aneurism,  aortic  regurgitation,  visceral  and  cerebral 
syphilis,  doubtful  cutaneous  and  arthritic  and  osseous  lesions.  Also  in 
tabes  and  dementia  paralytica. 


Fig.  250. — Trypanosoma  in  Human  Blood.     (By  permission  of  Dr.  J.  Everett  Dutton  and 

the  hondon  Lancet.) 

VI.  Blood  Parasites. 
I.   The  Malarial  Parasite  (see  Plates  IV.  and  V.). 

In  films  stained  as  above  directed  the  malarial  parasite  appears 
blue  against  the  pink  background  of  the  corpuscle.  A  crimson- 
stained  dot  should  appear  in  some  portion  of  the  blue-stained  organism ; 
the  protoplasm  of  the  red  corpuscle  around  it  is  often  studded  with 
pink  dots. 

The  stained  specimen  is  preferable  to  the  fresh  blood  in  the  search 


454 


PHYSICAL  DIAGNOSIS 


for  malarial  parasites,  for  the  young,  ring-shaped,  or  "hyaline"  forms 
often  escape  notice  altogether  in  fresh  specimens. 

Tertian  organisms   are   distinguished   from   the  aestivo-autumnal 
variety  by  the  following  tests : 


Fig.  251. — The  Filaria  Sanguinis  llominis.  The  head,  curled  up,  is  seen  to  the  right 
of  the  cut,  the  tail  to  the  left.  Instantaneous  photomicrograph.  Four  hundred  diameters 
magnification. 


Fig.  252. — Pratt's  Modification  of  the  Brodie-Russell  Coagulometer.  R,  Brass  ring 
soldered  to  glass  slide;  G,  cover  glass;  a  blood  drop  on  the  under  side  of  this,  when  in  place 
on  the  brass  ring,  is  close  to  the  point  of  the  hollow  metal  needle  which  forms  the  extremity 
of  the  inflation  tube,  C. 

(a)  Tertian  parasites  make  the  corpuscle  containing  them  larger 
than  its  uninfected  neighbors. 

(b)  Segmenting  forms  never  occur  in  the  peripheral  blood  of  aestivo- 
autumnal  fevers. 


Cabot — Physical  Diagnosis. 


PLATE  V. 


Fig.  I. — Two  Young  /^Jslivo-autumnal  Parasites.     (Wright's  modifiication  of  Leishman's 

stain.) 


Fig.  2. — ^stivo-autumnal  Parasites.     Ring  body  at  the  left;  crescent  at  the  right.     Stained 

like  Fig.  i. 


Fig.  3. — Ovoid  in  ^stivo- 
autumnal  Malaria. 


Fig.  4. — Crescent  in  ^stivo-autumnal  Malaria. 


THE  BLOOD  455 

(c)  "Crescents''  (see  Plate  V.)  never  occur  except  in  sestivo- 
autumnal  fevers. 

2.   The  Trypanosoma. 

In  Central  Africa  (and  presumably  in  other  tropical  countries)  the 
blood  or  gland  juice  of  many  persons  contains  the  organism  shown 
in  Fig.  250,  which  has  long  been  known  as  a  parasite  of  the  blood  of 
horses  and  of  many  of  the  lower  animals.  Human  trypanosomiasis — 
a  chronic,  debilitating  malady — becomes  "sleeping  sickness"  when  the 
trypanosoma  enters  the  cerebrospinal  canal. 

3.  Filariasis. 

In  the  blood  of  many  inhabitants  of  tropical  countries  there  is 
found  (with  or  without  symptoms)  the  parasite  shown  in  Fig.  251. 
The  species  most  often  found  is  present  in  the  peripheral  blood  only 
at  night;  hence  the  blood  should  be  examined  after  8  p.  m.  A  fresh 
drop  is  spread  between  slide  and  cover  and  examined  with  a  low-power 
lens  (No.  5  objective  Leitz). 


CHAPTER  XXV. 

THE  JOINTS. 

Examinations  of  the  Joints. 
A.  Methods  and  Data. 

I.   By  inspection  and  palpation  we  detect: 

1.  Pain,  tenderness,  and  heat  in,  near,  or  at  a  distance  from  the 
joint. 

2.  Enlargement: 

(a)  Hard,  probably  bony. 

(b)  Boggy,    probably   infiltration    or   thickening   of   capsule   and 
periarticular  structures. 

(c)  Fluctuating,  probably  fluid  in  the  joint. 

3.  Irregularities  in  contour: 

(a)   Osteophytes  or  "lipping"  (attached  to  the  bone). 
(6)   Gouty  tophi  (not  attached  to  the  bone) . 

(c)  Constriction-line  opposite  the  articulation. 

(d)  Protrusion  of  joint-pockets  in  large  effusions,   filling  out  of 
natural  depressions. 

4.  Limitation  of  motion: 

(a)  Due  to  pain  and  effusion. 

(b)  Due  to  muscular  spasm. 

(c)  Due  to  thickening  or  adhesions  in  the  capsular  and  periarticular 
structures. 

(d)  Due  to  obstruction  by  bony  outgrowths  or  gouty  tophi. 

(e)  Due  to  ankylosis. 

5.  Excess  of  motion  (subluxation). 

6.  Crepitus  and  creaking. 

7.  Free  bodies  in  the  joint. 

8.  Trophic  lesions  over  or  near  a  joint   (cold,   sweaty,  mottled, 
cyanosed,  white,  or  glossy  skin,  muscular  atrophy) . 

9.  Sinus  formation,  the  sinus  leading  to  necrosed  bone,  to  gouty 
tophi,  or  abscess  in  or  near  the  joint. 

10.  Distortion  and  malposition,  due  to  contractures  in  the  muscles 
near  the  joint,  to  necrosis,  to  exudation,  or  to  subluxation. 

456 


THE  JOINTS  457 

II.  Telescoping  of  the  joint  with  shortening  (hmb,  toe,  finger,  or 
trunk) . 

II.  By  radioscopy  we  investigate: 

1.  Bony  outgrowths,  their  shape,  extent,  and  position. 

2.  Necroses  and  atrophies  of  bone,  their  extent  and  position. 

3.  The  structure  of  the  bones  in  and  near  the  joints. 

4.  The  presence  of  lesions  in  the  articular  cartilages. 

5.  Free  joint  bodies,  their  presence  and  position. 

III.  Indirectly  we  may  gain  valuable  information  about  the  joints 
by  noting: 

1.  General  constitutional  symptoms,  their  presence  or  absence. 
These  include  fever,  chills,  leucocytosis,  glandular  enlargement, 
albuminuria,  and  emaciation. 

2.  Tuberculin  reaction  and  Wassermann  reaction,  perhaps  gono- 
coccus  fixation  test, — their  presence  or  absence. 

3.  Disease  of  other  organs,  their  presence  or  absence,  i.e.,  syphilis, 
tuberculosis,  tabes,  and  other  chronic  spinal-cord  lesions,  endocarditis, 
haemophilia,  various  acute  infections  (gonorrhoea,  influenza,  scarlatina, 
septicaemia),  and  skin  lesions  (psoriasis,  purpura,  hives). 

4.  The  course  of  the  disease  and  the  results  of  treatment. 

B.   Technique  of  Joint  Examination. 

(a)  Enlargement  is  generally  unmistakable,  but  when  there  is 
much  muscular  atrophy  between  the  joints  the  latter  may  seem  en- 
larged by  contrast,  when  in  fact  they  are  not.' 

{h)  Fluctuation  is  obtained  in  most  joints,  as  in  any  part  of  the 
body,  by  pressing  a  finger  on  each  of  two  slightly  separated  spots 
in  the  suspected  area,  and  endeavoring  to  transmit  through  the  inter- 
vening space  an  impulse  from  one  finger  to  the  other.  Fat  or  muscle 
will  also  transmit  an  impulse,  but  less  perfectly  than  fluid. 

In  the  knee  we  test  for  "floating  of  the  patella"  over  an  effusion 
by  surrounding  the  joint  with  the  hands,  which  are  pressed  slightly 
toward  each  other  to  limit  the  escape  of  fluid  in  either  direction,  and 
then  suddenly  making  quick  pressure  on  the  patella  with  one  finger. 
If  we  feel  or  hear  the  patella  knock  against  the  bone  below  and  rebound 
as  we  release  the  pressure,  fluid  in  abnormal  quantity  is  present. 

(c)  Irregidarities  of  contour  are  easily  recognized,  provided  the 
normal  contour  is  familiar. 

{d)  Bony  outgrowths  may  be  obvious  (as  in  Heberden's  nodes),  but 
if  within  the  joint  they  may  be  recognized  only  by  the  sudden  arrest  of 


458  PHYSICAL  DIAGNOSIS 

an  otherwise  free  joint  motion  at  a  certain  point.  In  many  cases  radio- 
scopy is  necessary. 

{e)  Gouty  tophi  are  identified  positively  by  transferring  a  minute 
piece  to  a  glass  slide,  teasing  it  in  a  drop  of  water,  covering  with  a  cover 
glass,  and  examining  with  a  high-power  dry  lens  and  a  partly  closed 
diaphragm.     The  sodium  biurate  crystals  are  characteristic. 

Fluid  or  semi-fluid  exudates  in  joints  may  fill  up  and  smooth  out 
the  natural  depressions  around  the  joint,  or,  if  the  exudate  is  large, 
may  bulge  the  joint  pockets;  in  the  knee-joint  four  eminences  may 
take  the  place  of  the  natural  depressions,  two  above  and  two  below 
the  patella. 

(/)  Limitations  of  m,otion  due  to  muscular  spasm  are  seen  with 
especial  frequency  in  tuberculous  joint  disease,  but  may  occur  in 
almost  any  form  of  joint  trouble,  particularly  in  the  larger  joints. 


Fig.  253. — Testing  for  Psoas  Spasm.     (Bradford  and  Lovett.) 

(i)  Hip-joint,  two  forms  of  spasm  are  important;  (i)  That  which 
is  due  to  irritation  of  the  psoas  alone  (psoas  spasm) ;  (2)  that  in  which 
all  the  muscles  moving  the  joint  are  more  or  less  contracted. 

In  pure  psoas  spasm  the  thigh  is  usually  somewhat  flexed  on  the 
trunk,  though  this  may  be  concealed  by  forward  bending  of  the  latter. 
Very  slight  degrees  of  psoas  spasm  may  be  appreciable  only  when, 
with  the  patient  lying  on  his  face,  we  attempt  hyperextension  (see 
Fig.  253). 

The  other  motions  of  the  hip — rotation,  adduction,  abduction,  and 
flexion — are  not  impeded. 

General  spasm,  of  the  hip  muscles  is  tested  with  the  patient  on  the 
back  upon  a  table  or  bed  (a  child  may  be  tested  on  its  mother's  lap) 
and  the  leg  flexed  to  a  right  angle,  both  at  the  knee  and  at  the  hip. 


THE  JOINTS  459 

Using  the  sound  leg  as  a  standard  of  comparison,  we  may  then  draw 
the  knee  away  from  the  middle  line  (abduction) ,  toward  the  past  and 
middle  line  (adduction),  and  toward  the  patient's  chest  (flexion). 
Rotation  is  tested  by  holding  the  knee  still  and  moving  the  foot  away 
from  the  median  line  of  the  body  or  toward  and  across  it. 

(2)  Spinal  column.  Muscular  spasm  of  the  muscles  guarding 
motion  in  the  vertebral  joints  can  be  tested  by  watching  the  body 
attitude  (a  stiff,  "military"  carriage  in  most  cases),  and  by  efforts  to 
bend  the  spine  forward,  backward,  and  to  the  sides. 

In  most  cases  we  can  make  out  limitation  of  these  motions  by 
asking  the  patient  to  stand  with  knees  and  hips  stiff  and  then  bend 


Fig.  254. — Rigidity  of  Spine  in  Pott's  Disease. 

his  trunk  (of  course,  naked)  as  far  as  he  can  in  each  of  the  four  direc- 
tions. If  we  are  familiar  with  the  average  range  of  motility  in  each 
direction  and  at  the  different  ages,  this  test  is  usually  easy  and  rapid. 
Backward  bending  is  the  least  satisfactory,  and  in  doubtful  cases  the 
patient  should  be  on  his  face,  while  the  physician,  standing  above  him, 
lifts  the  whole  body  by  the  feet  (see  Fig.  254). 

(3)  In  the  joints  of  the  shoulder,  knee,  elbow,  wrist,  ankle,  toes, 
and  fingers,  there  is  usually  no  difficulty  in  testing  for  muscular  spasm, 
and  no  special  directions  are  needed. 

To  distinguish  muscular  spasm  from,  bony  outgrowth  as  a  cause  of 
limited  joint  motion,  we  should  notice  that  bony  outgrowths  {e.g.,  in 
the  hip)  allow  perfectly  free  motion  up  to  a  certain  point ;  then  motion 
is  arrested  suddenly,  completely,  and  without  great  pain.     Muscular 


460  PHYSICAL  DIAGNOSIS 

spasm,  on  the  contrary,  checks  motion  a  little  from  the  outset,  the 
resistance  and  pain  gradually  increasing  until  our  efforts  are  arrested 
at  some  point,  vaguely  determined  by  our  strength  and  hard-hearted- 
ness  and  by  the  patient's  ability  to  bear  the  pain. 

Motions  limited  by  capsular  thickening  and  adhesions  are  not,  as 
a  rule,  so  painful  after  the  first  limbering-up  process  is  over.  There 
is  no  sudden  arrest  after  a  space  of  free  mobility,  but  motion  is  limited 
from  the  first  and  usually  in  all  directions,  though  the  muscles  around 
the  joint  are  not  rigid.  The  possibility  of  more  or  less  limbering-out 
after  active  exercise  (or  passive  motion)  distinguishes  this  type  of 
limitation. 

In  true  ankylosis,  there  is  no  motility  whatever. 

(g)  Excessive  motion  in  a  joint  is  recognized  simply  by  contrast 
with  the  limits  furnished  us  by  our  knowledge  of  anatomy  and  of  the 
physiology  of  joint  motion  at  different  ages.  When  the  bone  and 
cartilage  appear  normal  or  are  not  grossly  injured,  we  call  the  excessive 
motility  of  the  joint  a  subluxation,  but  excessive  motility  may  also  be 
due  (as  in  Charcot's  joint)  to  destruction  of  bone  and  other  essentials 
of  the  joint. 

Qi)  To  detect  crepitus  and  creaking  we  simply  rest  one  hand  on  the 
suspected  joint,  and  with  the  other  put  it  through  its  normal  motions, 
while  the  patient  remains  passive. 

{i)  Most  free  joint  bodies  are  not  palpable  externally,  and  are  rec- 
ognized only  by  their  symptoms,  by  the  ^-ray,  and  by  operation. 

(7)  Shortening  of  a  limb  as  evidence  of  joint  lesions  is  tested  by 
careful  measurements.  The  vast  majority  of  such  measurements  are 
made  with  reference  to  the  hip-joint.  The  tip  of  each  anterior  superior 
iliac  spine  is  marked  with  a  skin-pencil,  and  likewise  the  tip  of  each 
inner  malleolus.  Then,  with  the  patient  lying  at  full  length  on  a  flat 
table,  the  distance  from  anterior  superior  spine  to  inner  malleolus  is 
measured  with  a  tape  on  each  side. 

The  method  of  obtaining  the  other  data  tabulated  on  page  456 
needs  no  explanation,  except  the  radioscopic  technique^a  subject 
which  I  am  not  competent  to  discuss. 

C.  Joint  Diseases. 

I  shall  use  the  classification  proposed  by  Goldthwait  and  divide 
joint  diseases  as  follows: 

1.  Infectious    arthritis:    (a)    Tuberculosis.      (6)   Other    infections. 

2.  Atrophic  arthritis:  (a)  Primary.  (&)  Secondary  to  organic 
nerve  lesions  (Charcot's  joint). 


THE  JOINTS  461 

3.  Hypertrophic  arthritis. 

4.  Gouty  arthritis. 

5.  HasmophiHc  arthritis. 

Under  infectious  arthritis  are  included  all  varieties  of  articular 
"rheumatism"  and  the  joint  troubles  symptomatic  of  gonorrhoea,  of 
streptococcus  infections  (including  scarlet  fever),  influenza,  syphilis, 
typhoid,  and  other  fevers.  As  tuberculosis  is  an  infection  we  must 
include  it  in  this  group,  although  the  disease  begins  usually  as  an 
osteitis  and  involves  the  joint  secondarily  by  extension. 

I.  Tuberculous  Arthritis. — The  characteristics  of  joint  tuberculosis 
are: 

(a)  Slow  progress,  with  gradual  enlargement  and  disabling  of  the 
joint. 

{h)   Muscular  spasm,  especially  in  disease  of  the  hip  or  vertebras. 

(c)  Evidences  of  low-grade  inflammation  (moderate  heat,  swelling, 
pain,  and  tenderness). 

(J)   Abscess  and  sinus  formation. 

{e)  Malpositions  {e.g.,  shortening  of  one  leg  in  hip-joint  disease, 
angular  backward  projection  in  spinal  disease,  subluxations  in  the 
knee-joint). 

(/)   Bone  necrosis,  as  shown  by  :r-ray. 

The  order  of  frequency  in  the  different  joints  is  as  follows:  spine, 
hip,  knee,  wrist,  shoulder  (tuberculous  dactylitis  is  described  on 
page  55). 

In  the  deep-seated  hip-joint,  diagnosis  has  to  depend  largely  on 
shortening  and  on  the  presence  of  limitation  of  all  the  hip  motions  by 
muscular  spasm  (see  above,  page  458),  unless  the  disease  is  of  long 
standing  and  manifests  itself  by  abscesses  burrowing  to  the  surface. 
Usually  these  abscesses  point  in  the  upper  anterior  thigh,  but  they 
may  open  behind  the  great  trochanter,  below  the  gluteus  maximus,  or 
at  any  point  in  the  vicinity  of  the  hip. 

Besides  muscular  spasm,  shortening,  and  abscess  formation,  we 
get  some  aid  from  the  general  and  vague  joint  symptoms  present  in 
this  as  in  many  other  joint  lesions.  Such  are  enlargement  (felt  as 
thickening  about  the  great  trochanter),  muscular  atrophy,  pain,  ten- 
derness, and  crepitus. 

In  spinal  tuberculosis  {Pott's  disease)  the  distortion  of  the  bones 
with  formation  of  a  knuckle  in  the  back  is  often  obvious  and  practically 
diagnostic.  In  other  cases  we  depend  on  muscular  spasm  or  abscess 
formation.  The  muscular  spasm  gives  a  stiff  back  and  often  psoas  con- 
traction (see  below) .     The  abscess  is  peculiar,  in  that  it  usually  works 


462  PHYSICAL  DIAGNOSIS 

along  in  the  sheath  of  the  psoas  and  points  in  the  groin  below  Poupart's 
ligament  (see  Fig.  231);  less  often  it  appears  in  the  back  or  in  the 
gluteal  region,  and  rarely  it  may  invade  almost  any  part  of  the  body 
(lung,  gullet,  gut,  peritoneum,  rectum,  hip-joint,  etc.). 

Psoas  spasm,  which  is  common  both  in  hip  and  spinal  tuberculosis, 
is  by  no  means  peculiar  to  these  diseases,  and  it  is  worth  remembering 
that  it  may  be  due  to  various  other  lesions,  such  as : 

(a)  Hypertrophic  arthritis  of  the  spine. 

(b)  Appendix  abscess. 

(c)  Perinephritic  abscess. 

In  the  peripheral  joints  (shoulder,  elbow,  wrist,  finger,  knee, 
ankle)  the  diagnosis  of  tuberculosis  rests  on  the  chronic  enlargement 
and  disability,  with  abscess  and  sinus  formation. 

Hysterical  or  acute  traumatic  lesions  (with  or  without  neurosis) 
may  present  symptoms  and  signs  identical  with  those  of  tuberculosis. 
Decision  is  aided  most  by:  (a)  The  lapse  of  time  and  the  effects  of 
treatment.  (6)  X-ray  examination,  (c)  The  predominance  in  func- 
tional and  traumatic  cases  of  pain  and  tenderness  rather  than  muscular 
spasm  or  malposition. 

IL  Actite  Infectious  Arthritis. — All  varieties  are  distinguished  from 
the  other  types  of  arthritis  by:  (a)  The  absence  of  any  marked  bone 
lesions^  in  most  cases.  (6)  The  tendency  to  recovery  in  the  great 
majority  of  cases. 

The  milder  forms,  whose  cause  is  unknown,  we  have  hitherto 
designated  as  "rheumatism."  The  others  are  distinguished  as  gonor- 
rhoeal,  pneumococcic,  syphilitic,  influenzal,  dysenteric,  etc.,  according 
to  the  organism  producing  them. 

Between  this  group  and  those  known  as  "rheumatism,"  there  is 
no  clear  pathologic  distinction.  Mild  infection  with  pyogenic  cocci 
may  leave  a  sound  joint,  though  the  general  tendency  is  to  crippling 
through  fibrous  adhesions.  On  the  other  hand,  arthritis  of  "rheu- 
matic" {i.  e.,  of  unknown)  origin  may  end  in  suppuration,  crippling  the 
joint  with  adhesions,  though  in  most  cases  it  leaves  a  sound  joint. 

All  the  members  of  the  infectious  group  of  joint  lesions  present  the 
local  signs  of  infiammation  and  the  constitutional  signs  of  infection. 
All  may  be  complicated  by  endocarditis,  but  in  those  of  unknown 
origin  ("rheumatic")  this  complication  is  especially  common.  There 
is  no  bony  hypertrophy,  bone  destruction,^  sinus  formation,  or  marked 

*  Exceptionally,  virulent  infections  (especially  those  due  to  pneumococci  or  strepto- 
cocci) may  destroy  cartilage  and  bone  and  end  in  true  bony  ankylosis. 


THE  JOINTS 


463 


irregularities  of  contour.     A  general  enlargement  (more  or  less  spindle 
shaped,  owing  to  periarticular  thickening  and  muscular  atrophy)  is 


Fig.  255. — X-ray,  showing  Hands  in  Atrophic  Arthritis. 

the  rule.     The  joint  motions  are  limited  chiefly  by  pain  and  effusion; 
muscular  spasm  is  not  prominent. 


464 


PHYSICAL  DIAGNOSIS 


One  or  many  large  or  small  joints  may  be  affected  in  any  of  the 
varieties  of  infectious  arthritis,  though  the  gonorrhoeal  virus  is  apt  to 
lodge  in  few  joints  (oftenest  the  knee  or  ankle)  and  the  "rheumatic" 
virus  in  many  joints,  while  the  typhoid  poison  has  a  predilection  for 
the  spine. 

III.  Atrophic  Arthritis. — Two  types  must  be  recognized:  (a)  A 
monarticular  form,  secondary  usually  to  tabes  or  syringomyelia 
("Charcot's  joint,"  "neuropathic  joint"),  and  other  diseases  of  the 


Fig.  256. — a,  Charcot's  Joint  with  Loose  Bodies;  b,  Pulmonary  Osteo-arthropathy. 

spinal  cord,  (b)  A  polyarticular  primary  form  ("rheumatoid  ar- 
thritis" or  "anchylosing  arthritis"). 

In  both,  the  distinguishing  characteristic  is  atrophy  and  destruc- 
tion of  cartilage,  bone,  and  joint  membranes — a  process  which  in  the 
early  stages  can  be  identified  only  by  the  x-ray  (see  Fig.  255).  Later 
the  disintegration  of  the  joint  is  usually  evident,  and  is  followed  by 
distortions,  contractures,  and  ankylosis. 

(a)  The  monarticular  form  is  generally  easy  to  recognize  on  account 
of  its  rapid,  painless  course,  with  semifluctuant  swelling,  secondary  to 
a  well-marked  cord  lesion,  such  as  locomotor  ataxia.  A  large  joint  is 
almost  always  affected,  oftenest  the  knee,  less  often  the  hip,  shoulder, 
or  elbow.  The  joint  shows  abnormal  mobility  and  the  bones  can  often 
be  felt  to  grate  (see  Fig.  256). 


THE  JOINTS 


465 


Fig.  257. — Atrophic  Arthritis.     Early  stage. 


Fig.  258. — Atrophic  Arthritis.     (Goldthwait.) 


30 


466  PHYSICAL  DIAGNOSIS 

(b)  The  primary  polyarticular  form  usually  begins  in  the  fingers, 
and  is  very  apt  to  occur  symmetrically,  i.e.,  in  corresponding  joints  of 
both  hands  at  the  same  time  (see  Fig.  257).  The  joints  are  enlarged, 
boggy,  spindle  shaped  (owing  to  the  rapid  atrophy  of  the  interossei), 
often  abnormally  white,  apparently  fluctuant,  and  show  trophic  skin 
lesions  (glossy  skin,  sweating,  mottling)  (see  Fig.  258).  The  terminal 
finger-joints  are  rarely  swollen.  Late  in  the  course  of  the  disease  a 
ring  of  constriction  often  marks  the  line  of  articulation  (see  Fig.  259). 
Pain  is  not  severe  until  motion  is  attempted  or  unless  the  joint  is 
jarred  and  stirred  up  by  some  traumatism. 


Fig.   259. — ^Atrophic  Arthritis.     Late    stage  with    constriction    ring    at  the  joint  Une. 

(Goldthwait.) 

The  changes  progress  slowly  and  attack  new  and  larger  joints, 
moving  centrally  from  the  periphery.  At  any  stage  the  process  may 
become  arrested,  but  usually  not  until  ankylosis  or  contractures  have 
occurred  in  one  or  many  joints.  Some  of  the  "ossified  men"  of  dime 
museums  are  in  the  ankylosed  stage  of  this  terrible  malady.  Flexion 
of  fingers  with  hyperextension  of  the  terminal  joints  and  deflection  to 
the  ulnar  side  are  common  deformities. 

IV.  Hypertrophic  Arthritis. — This  is  a  degenerative  type  of  disease 
in  which  bony  enlargement  and  osteophytic  spurs  are  the  distinguish- 
ing feature.  The  new  bone  is  oftenest  deposited  round  the  edges  of 
the  articular  cartilage,  forming  an  irregular  fungoid  ring  ("ring  bone" 
in  horses)  or  "lip"  near  the  joint.     The  attachments  of  the  ligaments 


THE   JOINTS 


467 


(e.g.,  the  anterior  lateral  ligament  of  the  spine  or  the  cotyloid  ligament 
in  the  hip-joint)  furnish  another  favorite  site  for  the  bony  deposits. 
There  is  no  ankylosis  and  motion  is  limited  only  by  the  colHsion  of 
bony  spurs  in  joint  margins. 

(a)  In  the  terminal  finger-joints  (" Heberden's  nodes")  the  process 
may  remain  for  years  without  extending  to  any  other  articulation  and 
without  producing  any  discomfort  (Figs.  54  and  260). 

(&)  The  disease  may  be  limited  to  the  hip-joint  ("morbus  coxae 
senilis")   or  to  any  other  single  joint,  producing  purely  mechanical 


Fig.  260. — Hypertrophic  Arthritis  with  Heberden's  Nodes. 


disturbances  by  limitation  of  motion.  There  is  no  considerable 
muscular  spasm,  and  motion  is  quite  free  up  to  a  certain  point,  at 
which  it  is  suddenly  "locked"  by  the  interference  of  the  bony  out- 
growths. The  situation,  size,  and  shape  of  these  outgrowths  can  be 
shown,  as  a  rule,  by  the  jc-ray  alone.  Pain  and  swelling  are  slight  or 
absent,  unless  traumatism  (internal  or  external)  stirs  up  the  joint  and 
produces  a  synovitis.     The  chief  complaint  is  of  stiffness. 

(c)  Several  joints  may  be  affected,  and  there  may  result  much  pain 
because  nerves  pass  through  or  over  the  new-formed  bone  and  are 
compressed  by  it.     This  form  is  most  often  seen  in  the  spine  ("spon- 


468 


PHYSICAL  DIAGNOSIS 


dylitis  deformans,"  "osteoarthritis"),  where  a  portion  of  the  front 
and  side  of  the  vertebral  column  is  "plastered  over"  with  new- 
formed  bone  (see  Fig.  261),  which  later  invades  the  intervertebral 
cartilage  and  produces  (see  Fig.  262)  finally  either  a  straight  "ramrod" 
spine  or  a  forward  curved  spine. 


Fig.  261. — Hypertrophic  Arthritis  of  Spine.     (Goldthwait.) 


Non-tuberculous  disease  of  the  sacro  iliac  joint  has  already  been 
referred  to  on  page  58. 

In  the  early  stages  the  disease  is  recognized  by: 


THE  JOINTS  469 

(a)   Nerve  pain,  running  round  the  body  or  down  the  legs/  as  the 
intercostal  and  spinal  nerves  are  pressed  on. 


Fig.  262. — Hypertrophic  Arthritis  (Spine)  of  Spine  with  Anlcylosis.     (Goldthwait.) 


Fig.  263. — Showing  Normal  Flexibility  of  Spine.     (Goldthwait.) 

(6)  Limitation  of  Motion.  The  process  is  usually  unilateral,  wholly 
or  predominantly;  hence  the  patient  can  usually  bend  much  better  to 
one  side  (see  Figs.  263  and  264)  than  to  the  other.  Motion  is  also 
more  or  less  limited  in  other  directions,  but  forward  bending  is  fairly 

^  Many  neuralgias  and  sciaticas  are  due  to  this  disease. 


470 


PHYSICAL  DIAGNOSIS 


well  performed  as  a  rule,  in  sharp  contrast  with  "lumbago,"  which 
renders  forward  bending  and  the  subsequent  recovery  almost 
impossible. 


Fig.  264. — Hypertrophic  Arthritis  of  Spine.     Motion  to  left  limited.     (Goldthwait. 


Fig.  265. — Gouty  Tophus  in  the  Ear. 


(c)  Coughing  or  sneezing  often  gives  great  pain,  probably  because 
the  costo- vertebral  joints  are  involved  in  the  new  growth;  if  ankylosis 
of  these  joints  occurs  later,  the  respiratory  movements  of  the  chest  are 
interfered  with. 


THE  JOINTS 


471 


Fig.  266. — Gouty  Arthritis.     (Goldthwait.) 


Fig.  267. — A'-ray  of  Hand  in  Gouty  Arthritis.     (Goldthwait.) 


472  PHYSICAL  DIAGNOSIS 

V.  Gouty  Arthritis. — The  deposits  of  urate  of  sodium  in  the  soft 
structures  around  the  joint  are,  Hke  those  in  the  ear  (see  Fig.  265), 
close  beneath  the  skin  or  perforate  it,  and  hence  are  recognizable  (as 
above  explained)  by  microscopic  examination. 

They  somewhat  resemble  the  nodes  of  hypertrophic  arthritis,  but 
are  not  attached  to  the  bone  and  can  be  moved  about  in  the  soft 
structures  over  it.  X-ray  examination  shows  that  there  is  often  con- 
siderable destruction  of  bone  in  the  vicinity  of  the  tophi  (see  Figs. 
266  and  267). 

VI.  Hcemophilic  Arthritis. — A  chronic  stiffening  and  enlargement 
of  the  joint,  resembling  in  many  respects  the  joint  of  hypertrophic 
arthritis,  but  often  accompanied  by  the  formation  of  fibrous  adhesions, 
ensues  in  some  cases  of  haemophilia,  presumably  as  a  result  of  frequent 
hemorrhages  and  serous  oozings  in  the  joint.  The  diagnosis  depends 
on  the  evidence  of  haemophilia,  the  youth  of  the  patient,  and  the 
absence  of  infection  as  a  causative  factor. 

Relative  Frequency  of  the  Various  Joint  Lesions.^ — The 
following  table  was  prepared  by  Dr.  Vickery^  from  the  records  of  the 
Massachusetts  General  Hospital  (1893-1903): 

[  Acute  rheumatic  arthritis 591   | 

,   .      .  ...       I  Subacute  rheumatic  arthritis 103 

Infectious  arthritis.  <   ^           ,       ,       ,    .  .  „^   >  073 

I  Gonorrhoea!  arthritis 80 

[  Typhoid  arthritis  (spine) 3   J 

Hypertrophic  and  atrophic  arthritis 43 

Gout 9 

^  Chronic  villous  arthritis  ("dry  joint")  is  a  purely  local  process  and  therefore  receives 
no  further  mention  here. 

^Boston  Med.  and  Surg,   four.,  November  17,  1904. 


CHAPTER  XXVI. 

THE  NERVOUS  SYSTEM. 

Examination  of  the  Nervous  System. 

The  outlines  of  neurological  diagnosis  depend  on  knowledge  of: 

I.  Disturbances  of  motion. 

II.  Disturbances  of  sensation. 

III.  Disturbances  of  reflexes  (including  sphincteric  and  sexual 
reflexes) . 

IV.  Disturbances  of  electrical  excitability. 

V.  Disturbances  of  speech  and  handwriting. 

VI.  Disturbances  of  nutrition  ("trophic"). 

VII.  Psychic  disorders. 

I  shall  attempt  no  topical  diagnosis  of  nerve  lesions,  no  diagnosis, 
that  is,  depending  on  memorizing  the  brain  areas,  cord  levels,  or  skin- 
and-muscle  areas  corresponding  to  particular  nerve  lesions.  The 
general  practitioner  for  whom  this  book  is  intended  will  not  attempt 
to  carry  such  points  in  his  head,  but  will  refer  to  specialists  or  special 
text-books  when  the  case  confronts  him.  The  general  methods  most 
often  employed  are  all  that  I  attempt  to  describe. 

I.   Disorders  of  Motion. 

1.  Gaits. 

2.  Paralyses. 

3.  Spasms  and  tremors. 

4.  Ataxia. 

I.  Gaits. — The  most  important  gaits  are: 

(a)  The  spastic. 

(b)  The  ataxic. 

(c)  The  gait  of  paralysis  agiians. 

(d)  The  toe-drop  gait. 

(e)  The  gait  of  simple  weakfiess. 

With  the  spastic  gait  there  is  rigidity  of  the  legs,  making  it  difficult 
to  lift  the  feet;  hence  the  patient  scuffs  along,  usually  with  bent  knees 
and  as  if  his  feet  were  fastened  to  the  ground.^ 

'  The  cross-legged  gait  is  a  spastic  gait  in  which  the  adductors  of  the  thighs  are  so 
contracted  that  the  feet  tend  to  be  crossed.  This  gait  is  oftenest  seen  in  the  congenital 
spastic  paralyses. 

473 


474 


PHYSICAL  DIAGNOSIS 


The  ataxic  gait  is  difficult  to  describe.  The  patient  is  not  muscu- 
larly  weak,  but  does  not  know  where  his  feet  are  or  where  the  ground 
is;  hence  he  flounders  and  throws  his  feet  about  irregularly. 

The  gait  of  paralysis  agitans  is  an  exaggeration  of  the  old  man's 
gait,  such  as  we  often  see  on  the  stage.  The  whole  body  is  bent  for- 
ward and  rigid  (see  Fig.  268),  and, 
if  progress  is  accelerated  by  a  push 
given  from  behind,  the  patient 
may  be  unable  to  stop  himself. 

In  the  toe-drop  gait  the  foot  is 
raised  high  and  slapped  down  upon 
the  ground  with  a  flail-like  motion. 
2.  Paralysis  or  Paresis. — No 
detailed  account  can  be  given  here 
of  the  method  of  testing  individual 
muscles  for  loss  or  impairment  of 
power.  In  general,  a  knowledge 
of  the  origins  and  attachments  of 
muscles  enables  us  to  work  out  for 
ourselves  a  series  of  tests  that  will 
bring  any  desired  group  into  con- 
traction. It  is  convenient  to  class 
paralyses  according  to  their  origin 
as  follows : 

(a)  Brain  paralysis:  usually 
hemiplegia  (arm  and  leg  on  same 
side,  with  or  without  the  face) . 

(6)  Cord  paralysis:  usually /?ar- 
aplegia  (both  legs,  rarely  both  arms) 
or  monoplegia  (one  extremity). 

(c)  Cranial  nerve  paralysis: 
usually  one  or  more  eye  m,uscles. 

(d)  Peripheral  nerve  paralysis: 
special  muscle  groups,  oftenest  the 
extensors  of  the  wrist  or  foot,  the 

shoulder  muscles,  and  those  supplied  by  the  facial  nerve. 

(e)  Hysterical  paralysis:  no  strict  anatomical  distribution,  oftenest 
monoplegia  (one  extremity). 

Peripheral  nerve  paralyses  are  especially  apt  to  be  accompanied  by 
sensory  symptoms,  electrical  changes,  and  wasting.  Brain  paralyses 
have  relatively  few  sensory  symptoms  (sometimes  parsesthesiae,  see 


Fig.  26S. — Attitude  Characteristic  of 
Paralysis  Agitans. 


THE  NERVOUS  SYSTEM  475 

below,  page  477)  and  relatively  slight  wasting.  Mental  changes,  coma, 
or  convulsions  often  precede  or  follow  them.  Cord  paralyses  may  or 
may  not  show  these  associations,  but  are  often  accompanied  by 
disorders  of  the  bladder  and  rectum. 

3.  Spasm,  Tremor,  and  Fibrillary  Twitching. — (a)  Spasm  means 
involuntary  muscular  contraction.  The  familiar  "cramp"  is  a  good 
example  of  the  type  of  spasm  known  as  tonic  spasm.  In  contrast  with 
this  is  the  clonic  spasm,  in  which  flexors  and  extensors  contract 
alternately  to  produce  a  motion  like  that  of  our  forearm  when  we 
shake  up  a  fluid  in  a  test  tube,  or  like  the  ankle  clonus  (see  below) . 

Spasms  may  be  general  or  local,  i.e.,  involve  few  or  many  muscles. 
In  strychinine  poisoning  the  whole  body  may  be  thrown  into  rigidity 
or  general  tonic  spasm.  At  the  beginning  of  an  epileptic  seizure  the 
body  stiffens  out  (tonic  spasm),  then  becomes  "convulsed"  {general 
clonic  spasm).  Local  tonic  spasm  is  exemplified  in  the  ordinary 
''cramp."  The  spastic  gait,  above  described,  is  another  common 
example  of  tonic  spasm  limited  mainly  to  one  group  of  muscles.  The 
contractures  which  so  often  affect  the  sound  muscles  in  a  partially 
paralyzed  limb  (see  above,  page  474)  are  also  examples  of  local  tonic 
spasms. 

Athetosis,  a  special  variety  of  local  tonic  spasm,  has  been  described 
on  page  50. 

Local  clonic  spasm  is  not  common.  It  may  be  due  to  irritation  of 
a  small  portion  of  the  cerebral  cortex  by  various  lesions  ("  Jacksonian 
epilepsy"),  and  sometimes  precedes  or  alternates  with  the  general 
spasms  of  ordinary  epilepsy.     It  also  occurs  in  hysteria. 

Artificially  a  momentary  or  prolonged  clonic  spasm  of  the  foot 
muscles  is  often  produced  in  testing  for  the  ankle  clonus  (see  below, 
page  479). 

(&)  Tremor  may  be  defined  as  a  clonic  spasm  of  short  excursion. 
Its  causes  and  varieties  have  already  been  discussed  (see  page  45) . 

(c)  Fibrillary  twitchings  means  the  brief  repeated  contraction  of 
small  bundles  of  muscle  fibres.  It  is  seen  in  patients  who  are  cold  or 
nervous,  in  many  debilitated  and  neurasthenic  conditions,  and  often 
in  muscles  affected  by  progressive  muscular  atrophy. 

(d)  Choreic  and  choreiform  movements  have  already  been  described 
(page  47) . 

4.  Ataxia. — Inco-ordination  of  the  various  muscles  which  normally 
act  together  to  produce  a  well-directed  movement  is  called  ataxia.  All 
young  infants  exhibit  ataxia  in  their  more  or  less  unsuccessful  grasping 
movements.     AlcohoHc  intoxication   often  produces  typical   ataxia, 


476  PHYSICAL  DIAGNOSIS 

and  it  is  also  exemplified  in  the  gait  of  tabes  dorsalis.  There  is  no  lack 
of  muscular  contraction — often  too  much — but  it  is  disorderly  and 
ill-directed. 

Deficiency  in  the  power  to  balance  in  standing  or  walking  is  perhaps 
the  commonest  type  of  ataxia,  and  may  be  due  not  only  to  the  causes 
just  mentioned,  but  also  to  cerebellar  disease  and  ear  disease.  In  these 
types  there  is  often  a  tendency  to  stagger  in  one  particular  direction, 
e.g.,  to  the  right,  and  the  ataxia  is  associated  with  vertigo  and  with 
other  evidences  of  brain  tumor  or  of  ear  disease. 

In  tabes  dorsalis  and  other  diseases  we  test  the  power  to  balance 
by  asking  the  patient  to  bring  his  feet  together  (toe  to  toe  and  heel  to 
heel)  and  to  close  his  eyes.  If  he  is  unable  to  preserve  his  balance  his 
failure  is  known  as  "Romberg's  sign." 

II.  Disorders  of  Sensation. 

The  following  are  the  most  important  types : 

1.  AncBsthesia  (or  insensibility  to  pain,  to  touch,  to  heat  and  cold, 
and  to  muscle  sensation). 

2.  HypercjBsthesia  (or  oversensitiveness) . 

3.  Parcesthesia  (abnormal,  false,  or  disordered  sensation). 

4.  Pain. 

5.  Disorders  of  special  sense. 

These  disturbances  may  all  be  seen  in  different  stages  or  types  of 
lesions  of  the  spinal  cord  or  peripheral  nerves.  They  are  less  common 
in  brain  lesions. 

I.  Tests  of  ancesthesia  are  time-consuming  and  difficult,  because 
we  depend  for  our  data  on  the  patient's  intelligent  answer  to  the 
question,  "Do  you  feel  that?"  As  a  rule,  we  cover  the  patient's 
eyes  and  then  touch  the  suspected  parts — first  lightly,  then  more 
strongly — questioning  him  to  see  if  he  feels  the  touch,  can  judge  the 
nature  of  the  touching  object  (finger,  pencil,  pin),  and  tell  where  he  is 
touched.  A  pin-prick  is  oftenest  used  to  test  pain  sense,  and  test 
tubes  filled,  one  with  hot,  one  with  cold  water,  are  convenient  for 
trying  the  temperature  sense.  Finally,  we  try  whether  the  patient 
can  recognize  familiar  objects  placed  in  his  hand  and  can  tell  the 
position  in  which  you  may  put  his  arms  or  legs.  Failure  to  make  these 
discriminations  is  known  as  astereognosis,  and  occurs  oftenest  in  brain 
lesions  affecting  the  temporal  lobes. 

Dissociation  of  sensation — the  preservation,  for  example,  of  sensa- 
tions of  touch  with  loss  of  those  of  pain  and  temperature — occurs 
oftenest  in  syringomyelia. 


THE  NERVOUS  SYSTEM  477 

Delayed  sensation  and  mistakes  regarding  the  point  touched  in 
testing  are  commonest  in  tabes  dorsalis,  which  disease  presents  a 
great  variety  of  sensory  disorders  not  here  catalogued. 

The  distribution  of  anaesthesia  depends,  like  the  distribution  of 
paralysis,  on  the  lesion.  Hetniancesthesia  is  seen  oftenest  in  hysteria 
and  organic  brain  lesions.  Cord  lesions,  such  as  transverse  myelitis  or 
compression  oj  the  cord,  usually  produce  anaesthesia  in  the  area  supplied 
b}^  the  spinal  nerves  below  the  lesion.  Peripheral  nerve  lesions  may 
produce  anaesthesia  of  the  skin  areas  supplied  by  the  nerve  in  question. 

Areas  of  hysterical  ancBsthesia  (with  hyperaesthesia  and  paraesthesia) 
usually  do  not  correspond  to  the  distribution  of  any  set  of  nerves  or 
centres,  and  are  distinguished  by  this  fact. 

2.  Hypercesthesia  is  most  often  recognized  as  hyperaesthesia  for 
pain  (tenderness)  or  in  the  special  senses  (sensitiveness  to  light  or 
noise).  It  is  commonest  in  peripheral  nerve  lesions  and  in  hysteria. 
The  tests  are  the  same  as  those  for  anaesthesia. 

3.  Parcesthesia  is  commonest  in  the  form  of  the  familiar  prickling 
and  tingling  felt  when  one's  arm  or  leg  has  "gone  to  sleep."  Sensa- 
tions as  of  crawling  insects  are  not  uncommon;  the  "hot  feet"  of 
many  elderly  persons  (with  arterio-sclerosis)  and  the  "  burning  hands  " 
of  many  washerwomen  are  other  familiar  examples. 

Local  parcesthesia  is  not  uncommon  in  lesions  of  the  cerebral  cortex, 
and  constitutes  the  preliminary  "aura"  with  which  many  attacks  of 
epilepsy  are  ushered  in.  Well-developed  tabes  dorsalis  shows  many 
curious  or  distressing  varieties  of  paraesthesia,  as  do  many  other  varie- 
ties of  peripheral  neuritis. 

///.   Reflexes. 

We  may  distinguish: 

1 .  Pupil  reflexes. 

2.  Deep  reflexes  (tendon  reflexes). 

3.  Superficial  reflexes  (skin  reflexes). 

4.  Sphincter ic  reflexes. 

5.  Sexual  reflexes. 

1 .  Ptipil  reflexes  have  been  described  on  page  1 5 . 

2.  Tendon  Reflexes. — -Among  the  most  important  of  these  is  the 
knee-jerk  (quadriceps  tendon) ;  less  important  are  the  ankle-jerk 
(Achilles  tendon)  and  ankle  clonus,  the  wrist,  elbow,  and  jaw  reflexes. 

To  test  the  knee-jerk  many  methods  are  used;  the  following  seems 
to  me  the  best :  The  patient  sits  with  his  knees  flexed  at  a  blunt  angle. 
The  physician  lays  his  left  hand  on  the  front  of  the  thigh  and  strikes 


478  PHYSICAL  DIAGNOSIS 

the  tendon  of  the  quadriceps,  just  below  the  patella,  with  the  finger 
tips  of  the  right  hand  or  with  a  rubber  hammer.  The  left  hand  feels 
the  sudden  contraction  of  the  quadriceps  whether  the  foot  jerks  or  not. 
If  no  contraction  is  obtained  we  should  try  what  is  known  as  "reen- 
forcement  of  the  knee-jerk."  The  essence  of  this  is  concentration  of 
the  patient's  attention  on  a  voluntary  muscular  contraction  in  another 
part  of  the  body.  We  may  accomplish  this  by  asking  the  patient  to 
hook  the  fingers  of  his  hands  together,  and  at  a  given  signal  to  give  a 
quick  pull  upon  them  and  then  let  go.  The  physician  gives  the 
signal  (often  the  word  "now")  and  strikes  the  patella  tendon  at  the 
same  moment. 

The  knee-jerk  is  often  wanting  or  feeble  in  young  infants.  It 
varies  a  great  deal  in  persons  of  different  temperament;  in  high-strung 
or  oversensitive  persons  and  in  the  Jewish  race  very  lively  knee-jerks 
are  often  seen  without  disease. 

Absence  of  knee-jerk  is  oftenest  found  in: 

(a)  Peripheral  neuritis  (alcoholic,  diphtheritic,  lead,  etc.). 

(b)  Tabes  dorsalis. 

(c)  Anterior  poliomyelitis  (on  the  paralyzed  side). 

(d)  In  the  deepest  coma  from  any  cause. 

(e)  In  complete  severing  of  the  spinal  cord. 
Given  a  case  without  knee-jerks: 

Neuritis  is  suggested  by  the  history  (alcohol),  by  the  presence  of 
marked  sensory  symptoms  (pain,  tenderness),  and  the  absence  of 
symptoms  pointing  to  the  brain  or  cord. 

In  tabes  the  Argyll- Robertson  pupil,  the  disturbance  of  the  sphinc- 
ters and  sexual  power,  the  "lightning  pains"  here  and  there,  the 
presence  of  Romberg's  symptom  (see  page  476) ,  and  later  the  ataxic 
gait  are  important  confirmatory  signs. 

Anterior  poliomyelitis  presents  a  flaccid  paralysis,  usually  of  one 
extremity,  coming  on  suddenly  in  a  young  child  and  wholly  without 
sensory  symptoms. 

Comatose  patients,  if  the  coma  is  due  to  cerebral  hemorrhage  and 

is  not  of  the  profoundest  type,  often  show  increased  knee-jerks  on  the 

paralyzed  side;  but  in  very  profound  unconsciousness  all  reflexes  are 

lost. 

■   Partial  destruction  of  the  cord  often  increases  the  reflexes,  but  total 

■  division  usually  abolishes  them. 

Increased  knee-jerk  is  found  in : 

(a)  Cerebral  paralyses  (infantile,  apoplectic,  dementia  paralytica, 
etc.). 


THE  NERVOUS  SYSTEM  479 

(b)  Spastic  paraplegia  and  the  amyotrophic  forms  of  lateral 
sclerosis. 

(c)  Many  cord  lesions,  localized  above  the  lumbar  enlargement 
(transverse  or  pressure  myelitis) . 

(d)  The  earliest  stages  of  peripheral  neuritis. 

(e)  Multiple  sclerosis. 

(/)   Some  forms  of  chronic  arthritis. 

Differential  diagnosis  of  cases  with  increased  knee-jerks: 

Cerebral  paralyses  usually  manifest  their  place  of  origin  by  the 
presence  of  psychic  symptoms  (coma,  idiocy,  dementia)  and  by  con- 
vulsions. The  paralysis  is  usually  hemiplegic  and  involves  no  wasting 
beyond  the  atrophy  of  disuse. 

Spastic  paraplegia  is  readily  recognized  by  the  gait  (see  page  473) 
and  the  absence  of  marked  sensory  or  sphincteric  symptoms.  Its 
pathology  is  not  known.  If  marked  wasting  of  the  muscles  occurs  it 
is  termed  "amyotrophic  lateral  sclerosis." 

Transverse  or  diffuse  cord  lesions  above  the  lumbar  enlargement 
produce  usually  anaesthesia  below  the  level  of  the  lesion  and  almost 
invariably  relaxation  of  the  sphincters. 

The  earliest  stages  of  peripheral  neuritis  are  usually  recognizable, 
despite  a  lively  knee-jerk,  by  the  predominant  sensory  symptoms 
and  the  etiology. 

Multiple  sclerosis  presents,  in  typical  cases,  intention  tremor  (see 
above,  page  45),  nystagmus  (page  16),  and  staccato  speech.  In 
atypical  cases  diagnosis  is  difficult  and  cases  are  often  mistaken  for 
hysteria. 

Almost  any  chronic  joint  disease,  except  tuberculosis,  may  be 
associated  with  increased  reflexes.  Diagnosis  depends  on  the  absence 
of  other  causes  for  the  increase. 

Other  Deep  Reflexes. — The  Achilles  reflex  is  best  obtained  by 
having  the  patient  kneel  on  the  seat  of  a  well-padded  chair,  with 
his  feet  unsupported,  while  we  strike  the  Achilles  tendon.  The 
significance  of  its  absence  or  increase  is  practically  the  same  as  that 
just  given  for  the  knee-jerk,  but,  since  it  represents  a  slightly  lower 
position  in  the  spinal  cord,  it  may  be  affected  earlier  than  the  knee- 
jerk  in  any  cord  disease  which  begins  at  the  bottom  of  the  cord  and 
travels  up.  Thus  in  tabes  I  have  known  the  Achilles  reflex  absent 
when  the  knee-jerk  still  persisted. 

Ankle  clonus  occurs  in  spastic  conditions  of  the  legs  or  in  any 
disease  which  increases  the  other  leg  reflexes.  It  is  obtained  by 
supporting  the  patient's  leg  in  a  state  of  such  relaxation  as  can  be 


480  PHYSICAL  DIAGNOSIS 

obtained,  then  suddenly  and  quickly  forcing  the  foot  up  as  far  as  it 
will  go  toward  the  shin,  and  holding  it  in  this  position.  A  clonic 
spasm  results,  which  in  true  ankle  clonus  persists  as  long  as  we  choose 
to  hold  the  foot  in  this  position.  Spurious  clonus  is  obtained  when 
only  a  few  contractions  occur,  the  muscle  then  relaxing.  This 
spurious  clonus  can  often  be  obtained  in  neurasthenic  and  hysterical 
states,  and  has  not  the  significance  of  true  clonus. 

Kernig's  sign  is  a  reflex  contraction  of  the  ham-string  muscles, 
obtained  by  flexing  the  thigh  on  the  trunk  at  a  right  angle  (as  in  the 
ordinary  sitting  position)  and  then  attempting  to  extend  the  lower 
leg.  Its  motion  is  arrested  about  half  way  between  the  right  angle 
and  full  extension. 

This  reflex  is  of  some  value  in  the  diagnosis  of  meningitis,  though 
allowance  must  be  made  for  the  stiffness  of  old  age.  The  sign  is  by 
no  means  pathognomonic,  but  is  of  some  confirmatory  value. 

The  deep  reflexes  of  the  arms  (wrist,  biceps,  and  triceps  tendon) 
are  obtained  by  snapping  these  tendons  sharply  with  the  finger. 
Decrease  in  these  reflexes  we  cannot  perceive,  since  they  are  only 
obtainable  when  increased.  They  are  increased  in  practically  the 
same  diseases  which  increase  the  leg  reflexes,  and  also  in  some  chronic 
joint  troubles. 

The  jaw-jerk  is  obtained  by  asking  the  patient  to  let  the  lower 
jaw  drop  fully,  placing  a  finger  on  the  chin  and  percussing  that  finger 
as  in  percussion  of  the  chest.     It  can  be  elicited  only  when  increased. 

3.  Superficial  Reflexes. — A  "ticklish"  person  is  one  whose  super- 
ficial reflexes  (skin  and  muscles)  are  very  lively.  Among  pathological 
reflexes  of  this  type: 

(a)  The  Babinski  reflex  is  the  most  important.  It  is  a  modifica- 
tion or  reverse  of  the  normal  plantar  reflex,  which  crumples  up  the 
toes  toward  the  sole  of  the  foot  if  the  skin  of  the  foot  is  tickled. 

To  obtain  the  Babinski  reflex,  bare  the  patient's  foot  and  draw 
the  blunt  end  of  a  pencil  along  the  inner  side  of  the  sole  from  heel 
to  toe  with  moderate  pressure.  If  the  great  toe  cocks  up  toward 
the  shin,  Babinski's  reflex  is  present.  Sometimes  several  other  toes 
spread  laterally  and  follow  the  great  toe. 

The  reflex  is  obtained  on  the  paralyzed  side  in  hemiplegia  and 
other  lesions  involving  the  motor  tract. 

(&)  The  cremasteric  reflex  draws  the  testis  tight  up  against  the 
body  (as  after  a  cold  bath)  when  the  skin  and  muscles  on  the  inner 
side  of  the  thigh  are  gathered  up  and  firmly  grasped  in  the  hand. 

(c)   The    abdominal   and   epigastric    "tickle   reflexes"    are   excited 


THE  NERVOUS  SYSTEM  481 

by  lightly  and  quickly  stroking  the  skin  of  these  parts  with  a  pencil 
point  or  something  of  the  sort. 

The  presence  of  cremasteric,  abdominal,  and  epigastric  reflexes 
indicates  that  the  portion  of  the  spinal  cord  in  which  they  are  rep- 
resented (upper  lumbar  and  lower  dorsal  regions)  is  functionally 
sound.  The  absence  of  these  reflexes,  however,  signifies  nothing, 
for  in  many  healthy  persons  they  cannot  be  excited. 

(d)  The  reflex  of  winking  excited  by  the  ordinary  stimuli  signifies 
the  approximately  normal  conductivity  of  the  fifth  and  seventh  nerves 
(trigeminal  and  facial) . 

4.  S phincteric  Reflexes. — The  sphincters  of  the  bladder  and  rectum 
are  kept  closed  in  the  normal  adult  by  reflex  contraction,  normally 
of  moderate  degree,  but  excited  by  the  presence  of  urine  and  faeces. 
If  there  is  no  awareness  of  faeces  at  the  anus  or  of  urine  at  the  neck  of 
the  bladder,  owing  to  destruction  of  the  conducting  nerves  or  spinal 
nerve-centres,  involuntary  urination  and  defecation  occur. 

This  is  the  case  in  transverse,  diffuse,  or  compression  myelitis 
above  the  segment  (fourth  and  fifth  sacral)  where  the  centres  for 
bladder  and  rectum  are  represented;^  also  in  tabes  dorsalis,  dementia 
paralytica,  and  less  often  in  other  chronic  spinal  diseases.  Periph- 
eral neuritis  and  brain  lesions  rarely  affect  the  sphincters. 

In  deep  coma  from  any  cause  (epilepsy,  cerebral  hemorrhage) 
the  sphincters  may  be  relaxed,  owing  to  the  abolition  of  sensation. 

5.  Sexual  Power. — Sexual  power  may  be  regarded  as  a  reflex  in 
the  presence  of  a  particular  stimulus,  and  is  diminished  or  lost  in 
chronic  cord  diseases  involving  the  first  and  second  sacral  segments 
(lumbar  enlargement)  or  the  nerves  leading  to  them,  e.g.,  in  tabes, 
some  cases  of  myelitis  and  dementia  paralytica,  etc.  Temporary 
increase  of  power  may  precede  the  diminution. 

IV.  Electrical  Reactions. 

In  health  a  sharp  contraction  occurs  if  a  faradic  current  is  applied 
to  a  nerve  or  over  a  muscle,  and  a  similar  contraction  can  be  obtained 
with  the  galvanic  current  just  when  the  circuit  is  closed  or  broken, 
but  not  when  the  current  is  passing. 

In  contrast  with  these  conditions  is  the  reaction  of  degeneration. 
When   this   is   present   we   obtain  no   muscular   twitching   with   the 

'  It  must  be  reraembered  that  these  nerves  arise  from  the  cord  at  the  level  of  the  first 
lumbar  vertebra,  though  they  do  not  issue  from  the  spinal  column  till  the  fourth  and  fifth 
sacral  foramina  are  reached. 
31 


482  PHYSICAL  DIAGNOSIS 

faradic  current  and  none  over  the  nerve  with  the  galvanic;  but 
with  the  galvanic  over  the  ynuscle  a  slow,  worm-like  contraction  occurs, 
and  the  response  to  the  positive  pole  is  as  good  as  to  the  negative, 
or  better,  whereas  normally  there  is  far  better  response  to  the  negative. 
This  is  the  complete  reaction  of  degeneration;  in  partial  reactions  of 
degeneration  all  the  normal  reactions  may  be  present,  but  diminished 
in  intensity. 

Reaction  of  degeneration  occurs  in  all  diseases  affecting  the  anterior 
motor  horns  of  the  cord  or  their  prolongations  downward  in  the  per- 
ipheral nerves;  for  example,  in  anterior  poliomyelitis,  progressive 
muscular  atrophy,  transverse  or  pressure  myeltis,  and  all  severe 
forms  of  peripheral  neuritis.  In  brain  lesions  this  reaction  rarely 
occurs. 

In  prognosis  a  reaction  of  degeneration  persisting  after  six  to 
twelve  weeks  is  unfavorable  for  recovery  of  the  use  of  the  muscles 
in  which  it  occurs.  If  reaction  of  degeneration  is  absent  or  partial 
from  the  start,  the  prognosis  is  for  relatively  speedy  recovery,  i.e.,  in 
weeks  rather  than  months. 

V .  Speech  and  Handwriting. 

Aphasia,  the  loss  of  the  power  to  speak  or  understand  speech, 
despite  normal  hearing  and  muscular  powers,  occurs  in  lesions  affecting 
the  third  left  frontal  and  first  left  temporal  convolutions  of  the  brain.  ^ 

The  lesions  producing  aphasia  may  be  permanent  anatomical 
changes  following  hemorrhage  or  tumor,  or  they  may  be  transitory, 
as  in  uraemia  and  migraine. 

The  power  to  write  or  read  letters  is  lost  {agraphia)  when  the 
angular  and  supramarginal  convolutions  are  destroyed. 

Degeneration  of  the  handwriting,  as  compared  with  the  standard 
of  former  years,  is  often  a  helpful  bit  of  evidence  in  the  diagnosis 
of  dementia  paralytica,  but  may  occur  temporarily  in  various  fatigue 
states. 

VI.   Trophic  or  Vasomotor  Disorders. 

Trophic  lesions  of  the  joints,  muscles  (atrophy),  skin,  and  nails 
have  already  been  exemplified  (pages  464  and  54) .  They  blend  with 
and  are  by  some  explained  as  the  results  of  vascular  changes  {vaso- 
motor). Herpes  labialis  ("cold  sore")  and  herpes  zoster  ("shingles") 
certainly  seem  to  give  every  evidence  of  being  due  to  nutritive  dis- 

'  In  some  left-handed  persons  the  centres  are  on  the  right  side  of  the  brain. 


THE  NERVOUS  SYSTEM  483 

orders  in  the  ganglia  and  not  to  vascular  changes.  The  acute  bedsores 
which  form  in  myelitis,  the  "angioneurotic"  local  swellings  which 
appear  here  and  there  in  certain  persons,  and  the  local  syncope  or 
asphyxia  which  sometimes  lead  to  Raynaud's  form  of  gangrene, 
seem  to  need  both  nerve  and  vessel  changes  to  explain  them. 

In  brain  lesions  these  trophic  and  vasomotor  changes  are  much 
rarer  than  in  disease  of  the  cord  and  peripheral  nerves. 

VII.   The  Examination  of  Psychic  Functions. 

The  diagnosis  of  the  mental  factors  of  disease  forms  an  important 
part  of  the  study  not  only  of  neurology,  but  of  all  diseases  wherever 
situated;  but  as  it  cannot  be  called  physical  diagnosis,  it  falls  outside 
the  scope  of  this  book,  except  in  so  far  as  loss  of  consciousness,  coma, 
may  be  considered  under  this  heading. 

Coma. 

The  causes  of  coma  are  nearly  identical  with  the  causes  of  con- 
vulsions. Almost  every  disease  which  causes  the  one  may  cause  the 
other;  hence  all  that  is  here  said  on  the  diagnosis  of  coma  applies 
equally  well  to  the  diagnosis  of  convulsions.  Either  or  both  may 
result  from: 

1.  Apoplexy  (including  cerebral  hemorrhage,  embolism,  and 
thrombosis) . 

2.  Uraemia  and  hepatic  toxemia. 

3.  Diabetes. 

4.  Cerebral  concussion  (stun). 

5.  Cerebral  compression. 

6.  Syncope  (fainting). 

7.  Opium. 

8.  Alcohol. 

9.  Hysteria. 

10.  Epilepsy. 

1 1 .  Gas  poisoning. 

12.  Sunstroke. 

13.  Stokes-Adams'  syndrome. 

Apoplexy  is  the  probable  diagnosis  when  an  elderly  person  who 
has  shown  no  previous  signs  of  ill-health  becomes  suddenly  and 
deeply  comatose  within  a  few  seconds  or  minutes.  If  hemiplegia  is 
present  (with  or  without  aphasia)   and  if  we  can  exclude  the  other 


484  PHYSICAL  DIAGNOSIS 

causes  above  mentioned,  the  probability  of  apoplexy  is  increased. 
To  determine  hemiplegia  in  a  comatose  patient,  try  the  following 
tests : 

(a)  Lift  the  arm  and  then  the  leg,  first  on  one  side  and  then  on 
the  other,  and  let  go.  The  supported  member  falls  more  limply  on 
the  paralyzed  side. 

(6)  Pinch  or  prick  the  limbs  alternately.  The  sound  limb  may 
be  moved,  while  the  other  remains  motionless.  Pressure  over  the 
supraorbital  notch  may  bring  out  a  similar  difference  in  the  response 
of  the  two  sides. 

(c)  Try  the  knee-jerks.  On  the  paralyzed  side  the  jerk  may  be 
increased. 

(d)  Try  Babinski's  reaction.  It  may  be  present  on  the  paralyzed 
side  or  on  both  sides. 

Urcemia. — The  diagnosis  between  apoplexy  and  uraemia  is  some- 
times impossible,  since  uraemia  may  produce  hemiplegia  and  the 
urine  in  the  two  conditions  (as  obtained  by  catheter)  may  be  iden- 
tical. In  practically  all  cases,  however,  the  uraemic  patient  has  pre- 
viously shown  obvious  signs  of  nephritis — oedema,  headache  and 
vomiting,  long-standing  oliguria,  or  polyuria  with  albuminuria. 
"Acute  uraemia"  suddenly  appearing  in  a  person  apparently  healthy 
is  almost  always  a  false  diagnosis.  The  cases  turn  out  to  be  apoplexy, 
meningitis,  arteriosclerosis,  etc.  Convulsions  more  often  precede  or 
follow  the  coma  of  uremia  than  that  of  apoplexy.  Retinal  hemor- 
rhages or  albuminuric  retinitis,  if  recognized  by  ophthalmoscopic 
examination,  point  strongly  to  uraemia. 

The  hepatic  toxaemia  in  which  many  cases  of  cirrhosis  die  is  dis- 
tinguishable from  uraemia  only  if  the  previous  history  of  the  case  is 
known  to  us  and  the  signs  of  liver  disease  (ascites,  jaundice,  enlarged 
spleen)  are  evident. 

Diabetic  coma  is  usually  recognized  with  ease,  because  the  evidences 
of  advancing  diabetes  lead  gradually  up  to  it.  Like  uraemia  and  unlike 
apoplexy  it  very  rarely  appears  "out  of  a  clear  sky."  The  emacia- 
tion of  the  patient,  the  sweetish  odor  of  the  breath,  the  presence  of 
sugar,  and  especially  the  evidences  of  acetone  and  diacetic  acid  in 
the  catheter-urine,  are  the  essential  factors  in  diagnosis.  Dyspnoea 
("air  hunger")  precedes  the  coma  in  about  one-third  of  the  cases. 

Concussion  (or  stun)  after  a  blow  usually  clears  up  in  a  few  minutes 
and  so  presents  no  difficulty  in  diagnosis.  If  the  coma  lasts  on  for 
hours  or  days  (as  it  sometimes  does)  the  suspicion  arises  that  we  are 
dealing  with 


THE  NERVOUS  SYSTEM  485 

Compression.  For  this  the  evidences  are:  Focal  symptoms,  con- 
vulsions, slowing  of  the  pulse,  and  signs  of  depressed  fracture.  To 
determine  the  latter  fact  may  be  impossible  without  trephining,  since 
the  inner  table  of  the  skull  may  be  broken,  while  the  outer  is  intact. 
The  focal  signs  to  be  looked  for  are  paralyses  (ocular  or  peripheral). 

Syncope  (or  fainting)  is  usually  over  in  a  few  minutes  and  so  betrays 
its  nature,  but  it  must  not  be  forgotten  that  a  slight  convulsion  may 
occur  just  as  the  patient  comes  out  of  coma.  No  suspicions  of  epilepsy 
need  be  aroused  thereby,  but  if  there  have  previously  been  signs  of 
hysteria  we  may  be  in  doubt  whether  the  fainting  fit  is  not  of  hysterical 
origin.  The  history  of  the  case,  the  circumstances  at  the  onset  of  the 
attack,  and  the  presence  or  absence  of  hysterical  behavior  during  it 
usually  guide  us  aright. 

Opium  poisoning  produces  a  coma  from  which  the  patient  can 
usually  be  more  or  less  aroused.  Contracted  pupils  and  slow  respi- 
ration are  the  most  characteristic  signs.  A  laudanum  bottle  or  a 
subcutaneous  syringe  found  near  the  patient  often  assist  the  diagnosis. 

Alcoholic  coma  is  rarely  complete.  The  patient  can  be  aroused. 
The  circumstances  under  which  he  is  found,  the  odor  of  alcohol  on 
the  breath,  the  absence  of  paralysis,  fever,  small  pupils,  or  urinary 
abnormalities  are  the  main  supports  in  diagnosis.  There  is  no  char- 
acteristic pulse  and  the  pupils  show  no  constant  changes,  though  in 
many  cases  they  are  dilated. 

Hysterical  coma  usually  occurs  in  young  women  who  have  pre- 
viously shown  signs  of  hysteria.  In  falling  they  never  hurt  them- 
selves. The  eyelids  are  contracted,  often  tremulous,  and  when 
forcibly  pulled  open  often  expose  eyeballs  rolled  up  so  that  the  whites 
alone  are  seen.  The  hands  are  apt  to  make  grasping  motions,  and 
there  are  irregular,  semipurposive  movements  of  various  parts  of  the 
body.  A  startling  word  may  arouse  the  patient,  but  anaesthesia  to 
pain  (over  one-half  or  all  the  body)  is  often  complete. 

Postepileptic  coma  is  usually  recognized  with  ease,  because  of  the 
convulsions  which  precede  it  and  which  are  usually  known  to  have 
occurred  at  intervals  before.  The  scars  of  previous  falls  may  be  found 
on  the  head. 

Gas  poisoning  rarely  presents  any  diagnostic  difficulties,  because  the 
circumstances  under  which  the  patient  is  found  make  clear  the  cause 
of  his  condition.  An  odor  of  gas  may  hang  about  his  breath  for  some 
hours. 

Sunstroke  is  recognized  by  the  state  of  the  weather  and  the  presence 
of  a  very  high  temperature  (io6°,  i  io°,  1 15°  F.,  or  even  more) .     There 


486  PHYSICAL  DIAGNOSIS 

is  no  other  characteristic  sign.     This  condition  is  to  be  distinguished 
from  heat  exhaustion  in  which  there  is  no  fever  and  no  coma. 

The  Stokes-Adams'  Syndrome  (see  above  p.  114)  produces  coma  and 
convulsions  with  a  very  slow  radial  pulse  and  a  quicker  venous  pulse 
(visible  or  traceable  polygraphically)  in  the  neck. 


INDEX 


Abdomen,  contour  of,  339 

distended  and  tortuous  veins  of, 

339 
examination  of,  338—342 
free  fluid  in,  345,  347 
inspection  of,  339 
organs  palpable  in,  341 
palpation  of,  340 
projection  or  levelling  of  navel, 

339 
respiratory  movements  of,  340 
rose  spots  on,  339 
strias  of,  339 
tumors  of,  343 
tumors  of,  frequency  of,  346 
tumors    of,  respiratory    mobility 

in,  343 
Abdominal  distention,  378 

reflexes,  480 

wall,  abscess  of,  342 

wall,  inflammation  of,  343 

wall,  lesions  of,  346 

wall,  movements  of,  339 

wall,  sarcoma  of,  343 

wall,  thickening  of,  343 
Abscess,  alveolar,  25 

axillary,  40 

cervical,  caries  in,  29 

cervical  in  Pott's  disease,  32 

cold,  59,  70 

glandular,  32 

in  tuberculous  arthritis,  461 

ischiorectal,  414 

of  abdominal  wall,  342 

of  hip-joint,  58 

of  liver,  348 

of  lung,  breath  in,  2  i 

of  urethra,  419 

peri -urethral,  416 

perihepatic,  348 


Abscess,  perinephritic,  59,  391 

perinephritic,    psoas    spasm    in, 
462 

perisplenic,  348 

psoas,  426 

pulmonary,  293,  333 

pulmonary,  sputa  in,  303 

retropharyngeal,  28 

subphrenic,  348 

tonsillar,  28 

tuberculous,  59 
Acetone  breath,  22 
Achilles  reflex,  479 
Achromia  of  red  cells  in  chlorosis,  448 
Achylia  gastrica,  stomach  contents  in, 

361 
Acne  rosacea,  nose  in,  18 
Acromegalia,  8 

arm  in,  43 

hands  in,  52 

nose  in,  8,  17 

"whopper  jaw"  in,  8 
Actinomycosis,  59 

of  belly-wall,  343 

of  neck,  35 

of  pleura,  330 
Addison's  disease,  106 

disease,  buccal  patches  in,  26 
Adenitis,  29,  92,  93 
Adenoid  growths,  64 

growths,  nose  in,  18 
Adenoids,  11 

lips  in,  19 
Adherent  pericardium,  84,  203,  260 
Agraphia,  482 
Albuminuria,  398 

in  peritonitis,  347 

significance  of,  399 

with  nephritis,  400 

without  nephritis,  400 


487 


488 


INDEX 


Albumosuria,  significance  of,  400 
Alcoholism,  364,  478 

breath  in,  22 

coma  in,  485 

face  in,  12 

hands  in,  44,  45 

in  myocarditis,  244 

nose  in,  17,  18 

pharyngeal  reflexes  in,  29 

skin  in,  100 

tongue  in,  23 
Alkaline  urine,  398 
Alopecia  areata,  patchy  baldness  in, 

7 
Amoeba  coli,  381 

histolytica  in  feces,  381 
Amyloid  disease,  of  liver,  365 

disease,  spleen  in,  389 
Amytrophic  lateral  sclerosis,  479 
Anaesthesia,  hysterial,  477 

neuritis  after,  37 

tests  of,  476 
Anatomy  of  chest,  61 
Anemia,  capillary  pulsation  in,  90 

functional  heart  murmurs  in,  187 

haemoglobin  test  in,  439 

hypertrophy  in,  198 

interpretation  of  blood  count  in, 
448 

lips  in,  19 

mitral  stenosis  in,  217 

murmurs  in,  225 

nails  in,  57 

oedema  of  legs  in,  431 

oedema  of  lids  in,  14 

pallor  in,  92 

pernicious,  106,  448 

pulse  in,  221 

retinal  hemorrhage  in,  17 

splenic,  389 

venous  murmurs  in,  189 

secondary  causes  of,  447 
Aneurism,  34,  59,  70,  82,  85,  86,  239, 

263,  327,  334 
aortic,  299 
aortic,  pupils  in,  16 
cardiac,  214 
diagnosis  of,  270 
diffuse,  219,  263 


Aneurism,    distinguished  from  aortic 
stenosis,  271 

distinguished  from  diffuse  dilata- 
tion of  the  arch,  without 
rupture  of  coats,  271 

distinguished  from  empyema 
necessitatis,  272 

distinguished  from  mediastinal 
tumors,  272 

location  of,  269 

oedema  of  arm  in,  40 

of  aorta,  231 

percussion  signs  in,  264,  266 

pulsation  in,  263 

pupils  in,  266 

radial  pulse  in,  266 

radioscopy  in,  268 

saccular,  220,  263 

thoracic,  263 
Angina  pectoris,  196,  244,  312 
Angioneurotic  oedema,  14,  20,  483 

oedema  of  legs,  432 
Ankle  clonus,  spasm  in,  475 

clonus,  test  for,  479 
Ankylosis,  460,  466 
Anorexia  in  local  peritonitis,  347 

nervosa,  malnutrition  in,  2 
Anterior  poliomyelitis,  428 

poliomyelitis,  acute,  paralysis  in, 
38 

poliomyelitis,  knee-jerk  in,  478 

poliomyelitis,     reaction     of     de- 
generation in,  481 
Anus,  fistula  of,  414 

fissure  of,  414 
Aortic  aneurism,  see  Aneurism- 
arch.,  dilatation  of,  219,  226 

arch,  roughening  of,  231,  239 

dilatation,  209,  231 

insufficiency,  216 

obstruction,  see  Stenosis 

regurgitation,  see  Regurgitation 

second  sound,  173,  174,  175 

stenosis,  see  Stenosis  aortic 

valves,  roughening  of,  226 
Aortitis,  syphilitic,  218 
Apex  retraction,  83 
Aphasia,  247,  482 
Aphonia,  258 


INDEX 


489 


Apnoea  in   Cheyne-Stokes  breathing, 

75 
Apoplexy,  breathing  in,  76 

coma  in,  483 

distinguished  from  ursemia,  484 
Appendicitis,  375 

cause  of  peritonitis,  345 

diagnosis  of,  376 

leucocytosis  in,  449 

local    and    constitutional    signs, 

376 

muscular  spasm  in,  376 

psoas  spasm  in,  376,  462 

simulated,  376 

tenderness  in,  376 

tumor  in,  376 
Arcus  senilis,  16 
Argyll-Robertson  pupil,  16,  478 
Arms,  artophy  of,  39 

contractures  of,  39 

contractures  of,  in  cerebral  lesion, 

39 
contractures  of,  in  hysteria,  39 
cyanosis  of,  266 
deep  reflexes  of,  480 
fatty  tumors  of,  40 
gouty  deposits  in,  41 
in  acromegalia,  43 
in   acute    anterior   poliomyelitis, 

38,  39 
in  osteoarthropathy,  43 
in  Paget's  disease,  42 
in  rickets,  42 
oedema  of,  266 
oedema  of,  causes  of,  40 
oedema  of,  in  aneurism,  40 
oedema  of,  in  cancer,  40 
oedema  of,  in  Hodgkin's  disease, 

40 
oedema  of,  in  nephritis,  40 
oedema  of,  in  sarcoma   of  medi- 
astinum, 40 
oedema  of,  in  sarcoma    of  lung, 

40 
oedema  of,  in  thrombosis,  40 
pain  in,  35,  266 
paralysis  of,  37 
sarcoma  of  bone  of,  40 
tuberculosis  of  bone  of,  4 1 


Arms,  tuberculous  lesions  of,  41 
Arrhythmia,  213,  222,  247,  250 

causes  of,  102 

"nervous,"  218 
Arsenic  poisoning  with  conjunctivitis, 

15 
Arterial  embolism,  215 
murmurs,  189,  190 
pressure,  107 
tension,  104,  106 
walls,  calcification  of,  106 
walls,  condition  of,  105 
walls,  stiffening  of,  105,  106 
Arteries,  calcification  of,  105 
changes  in,  40 
diseases  of,  89 
inspection  of,  88 
position  of,  105 
pulsation  in,  see  Pulsation 
stiffening  of,  89 
Arteriograms,  113 

Arterio-sclerosis,     82,     89,    105,    107, 
III 
cornea  in,  16 
gangrene  of  toes  in,  435 
heart  sounds  in,  174 
hypertrophy  in,  198 
pulse  in,  103 
Arthritis,  425 

acute     infectious,     distinguished 

from  other  types,  462 
acute  infectious,  endocarditis  in, 

462 
atrophic,  54,  464 
atrophic,  monarticular  form,  464 
atrophic,  of  sacro-iliac  joint,  467 
atrophic,    primary   polyarticular 

form,  466 
atrophic,    symmetrical    involve- 
ment of  joints  in,  466 
atrophic,  X-ray  of  hand  in,  464 
gouty,  472 
hsemophilic,  472 
hypertrophic,  features  of,  466 
hypertrophic,   Heberden's  nodes 

in,  466 
hyertrophic,  limitation  of  motion 

in,  469 
hypertrophic,  nerve  pain  in,  469 


490 


INDEX 


Arthritis,  Hypertrophic,  of  sacro-iUac 
joint,  58 
hypertrophic,     psoa    sspasm    in, 

462 
hypertropic,  with    kyphosis,  58 
infectious,  461 
spinal,  57 

tuberculous,     characteristics    of, 
461 
Ascaris  lumbricoid.es,  381,  384 
Ascites,  422 

causes  of,  347 
Asphyxia,  local,  in  Raynaud's  disease, 

55 
Astereognosis,  476 
Asthma,  277 

breathing  in,  153 

bronchial,  276,  300 

bronchial,  eosinophilia  in,  450 

thymic,  301 
As- Vs  interval,  114 

-Vs  interval,  in  mitral  stenosis, 
213 
Ataxia,  475 

Romberg's  sign  in,  476 
Atelectasis,  268,  275,  284,  335 

creptant  rales  in,  160 

pulmonary,  328 
Athetosis,  50 

Atrophic  arthritis,  see  Arthritis 
Atrophy,  acute  yellow,  368 

following  fracture  or  dislocation, 

39 
of  disuse,  39 
in  hysteria,  39 
muscular,  claw  hand  in,  51 
muscular,   reaction  of  degenera- 
tion in,  482 
optic,  17 

progressive    muscular,    fibrillary 
twitching  in,  475 
Auricle,  dilatation  of,  202 

hypertrophy  of,  202 
Auricular  fibrillation,  115 
Auscultation,  differences  between  two 
sides  of  chest,  154 
importance  of,  137 
in  pneumohydrothorax,  165 
in   aortic  regurgitation,  222 


Auscultation  in  croupous  pneumonia, 
279 
in  mitral  stenosis,  212 
in  myocarditis,  245 
mediate  versus  immediate,    137, 

138 
of  heart,  167,  197 
of  lungs,  147 
of  muscle  sounds,  145 
of  voice  sounds,  see  Vocal  Frem- 
itus 
see     also    Breathing,     Murmurs, 

Rdles,  Heart  sounds 
sources  of  erorr  in,  146,  147 
technique  of,  137 
Austin  Flint  murmur,  215,  216,  226 

Babinski  reflex,  test  for,  480 
Bacilli  influenza,  305,  307 

pneumococcic,   305 

tubercle,  305,  380 

tubercle,  identification  of,  380 
Back,  57-60 

aneurism  pointing  in,  59 

dermoid  cyst  of,  60 

epithelioma  of,  60 

in  lumbago,  57 

nodes  in,  59 

spina  bifida  of,  60 

stiffness  of,  57 

tumors  of,  59,  60 
Balanitis,  416 
Baldness,  7 

patchy,  in  alopecia  areata,  7 
Basedow's  disease,  375 
Bathycardia,  84 
Bence-Jones'  body,  400 
Biceps,  rupture  of,  40 
Bigeminal  pulse,  119,  215,  249 
Bile  ducts,  368 

ducts,   incidence  of   diseases   of, 
362 
Bilharzia  disease,  blood  in,  450 

eggs,  385 
Biliary  colic,  369,  392 

obstruction,  15 
Bismuth  line,  24 

X-ray  examination  of  stomach, 
358 


INDEX 


491 


Bladder  disease,  incidence  of,  410 

disease,  percussion  in,  410 

disease,  urine  in,  412 

distention  of,  410 

pus  in,  396 

stone  of,  413 

tuberculosis  of,  413 

tumor  of,  398 
Blindness,  dilatation  of  pupil  in,  16 
Blood,  altered,  379 

color,  index  of,  438 

counting  red  corpuscles  of, 
method  of,  446 

counting  white  corpuscles, 
method  of,  445 

cover-glass  preparation  of,  439 

.eosinophilia  in,  444,  450 

examination  of,  437 

filaria  in,  455 

films,  appearance  of  stains,  442 

films,  preparation  of,  439 

films,  staining  of,  441 

films,  stains  used,  441 

haemoglobin  test,  437 

in  Bilharzia  disease,  450 

in  chlorosis,  448 

in  feces,  379 

in  filariasis,  450 

in  hydatid  disease,  450 

in  lymphoid  leukasmia,  450,    451 

in  myeloid  leukaemia,  451 

in  pernicious  anemia,  448 

in  secondary  anemia,  447 

interpretation  of  result  of  leuco- 
cyte count  and  differential 
count,  446 

in  trichiniasis,  450 

in  trypanosomiasis,  450 

in  uncinariasis,  450 

in  urine,  405 

leucocytes  in,  443 

lymphocytes  in,  443 

normoblasts  distinguished  from 
megaloblasts  in,  442 

nucleated  red  cells  in,  442 

occult,  380 

parasites  in,  453 

plates,  444 

poikilocytosis,  442 


Blood,  polychromasia,  442 

polynuclears  in,  443 

pressure,  see  Pressure 

stippled  red  cells  in,  442 

trypanosoma  in,  455 

Wassermann  reaction,  453 

Widal  reaction,  452 

see  also  Anemia 
Body,  as  a  whole,  i 
Bone,     necrosis    of,     in     tuberculous 

arthritis,  461 
Bowel,  cancer  of,  378 
Bradycardia,  248 
Brain,  abscess  of,  optic  neuritis  in,  17 

defects,  spasms  in,  14 

lesions,  astereognosis  in,  476 

lesions,  hemianaesthesia  in,  477 

lesions,  nystagmus  in,  16 

paralysis  of,  474 

tumor,  optic  neuritis  in,  17 
Breast,  funnel,  65 

pigeon,  65 
Breath,  22 

acetone,  22 

alcoholic,  22 

causes  of  foul,  22 

in  gastric  fermentation,  22 

in  poisoning  by  illuminating  gas, 
22 

in  Rigg's  disease,  22 

in  stomatitis,  22 

in  tonsillitis  follicular,  22 

in  uraemia,  22 
Breathing,  amphoric,  158,  292,  310 

asthmatic,  74 

bronchial,  150,  156,  157 

bronchial  or  tracheal,  150,  151 

broncho-vesicular,  152,  154,  157, 
158,  279,  290 

catchy,  76 

cavernous,  158,  292,  310 

Cheyne-Stokes,  75,  244 

cog-wheel,  152,  153,  286,  287 

compensatory,  155 

differences  between  two  sides  of 
chest,  154 

difficult,  72 

emphysematous,  72,  152,  298 

exaggerated  vesicular,  155 


492 


INDEX 


Breathing  in  apoplexy,  76 

in  asthma,  72,  153 

in  hysteria,  77 

interrupted,  152,  153,  287 

metamorphosing,  154 

normal,  70,  73 

rapid,  72,  73 

shallow,  76 

"sharp,"  290 

sighing,  76 

stertorous,  76 

stridulous,  76 

tubular,  143,  157,  258,  279 

types  of,  72,  73,  74,  148 

vesicular,  148,  149,  150,  274 

vesicular,  diminished,  155 

see  also  Respiration 
Bronchi,  dilatation  of,  see  Bronchiec- 
tasis 

spasm  of,  300 
Bronchial  asthma,  see  Asthma 

breathing,  see  Breathing 

pneumonia,  see  Pneumonia 
Bronchiectasis,  277,  293,  302 

sputa  in,  303 
Bronchitis,  acute,  274,  277,  284 

chronic,  277,  302 

tuberculous,  acute,  295 
Bronchophony,  164 
Buccal  cavity,  see  Mouth 
Bulbar  paralysis,  see  Paralysis 
Bundle  of  His,  114,  248 
Bursitis,  prepatellar,  429 

Cachexia,  273 

of  old  age,  i 
Calcaneus,  433 
Cancer,  272 

age  of  patient  in,  360 

anemia  in,  447 

gastric,     advanced,     symptoms, 
360 

gastric,  bismuth  X-ray  examina- 
tion in,  358 

gastric,  malnutrition  in,  2 

gastric,  statistics  of,  360 

gastric,  tumor  in,  351 

gastric  with   absence  of  hydro- 
chloric acid,  360 


Cancer,  glands  in,  3  i 

jaundice  in,  367 

metastatic,  of  femur,  426 

oedema  of  arm  in,  40 

of  bowel,  378 

of  esophagus,  353 

of  lip,  20 

of  liver,  364 

of  pancreas,  jaundice  in,  371 

of  penis,  416 

of  peritoneum,  348 

of  pleura,  329 

of  rectum,  414 

of  rectum,  stools  in,  379 

of  sigmoid,  377 

of  stomach,  360 

of  testis,  417 

of  tongue,  22 

of  tonsil,  28 

of  uterus,  420 

of  vertebrs,  57 

tongue  in,  23 
"Canker  sores,  "20 
Cardiac   compensation,    see   Com,pen- 
sation 

cycle,  see  Heart  cycle 

disease,  diuresis  in,  i 

disease,  sweating  in,  i 

disease,  weight  in,  i 

disease,  see  also  Heart 

dulness,  133,  212,  250,  275,  288, 

311,  319 

impulse,    94,    95,    185,    198,    220, 
243>  258,  260,  309,  322 

impulse,  character  of,  79-81 

impulse,  displacement  of,  62,  68, 
.82,  197 

impulse,  maximum,  79 

impulse,  normal,  79 

impulse,  position  of,  79 

murmurs,  see  Murm-urs 

neuroses,  81,  246 

space,  129 
Cardio-spasm,  353 
Caries  of  vertebrae,  abscess  in,  29 
Carphologia,  44 
Casts  in  urine,  463 
Catarrhal     pneumonia,      see     Pneu- 


INDEX 


493 


Cavity,  pulmonary,  292,  302 
Cervical  rib,  an  accessory,  35,  39 
Charcot's  joint,  atrophic  arthritis  in, 

462 
Chest,  anatomy  of,  61 

barrel  shaped,  66 

diminished  expansion  of,  71 

examination  of,  61 

flattening  of,  68 

in  adenoid  disease,  65 

increased  expansion  of,  72 

in  phthisis,  65,  66,  67,  68 

inspection  of,  64 

landmarks  of,  62,  63 

local  prominences,  69 

palpation  of,  94 

percussion  of,  121 

prominence  of  one  side,  69 

rachitic,  65 

shape  of  j  64 

size  of,  64 

tenderness  in,  99 

tumor  of,  70 

wall,  nutrition  of,  67 
Cheyne-Stokes  breathing,  75,  244 
Children,      splenic      enlargement     in, 

388 
Chill,  cause  of,  3 

true,  cause  of,  4 
Chilliness  distinguished  from  chill,  4 
Chlorosis,  blood  in,  448 

visible  pulsation  in,  84 
Cholangitis,  365 
Cholecystitis,  signs  of,  370 

results  of,  370 
Chorea,  hands  in,  47 

leg  in,  428 

post-hemiplegic,  49 

spasms  in,  13 

Sydenham's,  of  hands,  47 

true,  to  differentiate,  14 
Choreiform  movements,  47,  49,  50 
Cirrhosis  of  liver,  see  Liver 

of  lung,  see  Pneumonia,  chronic 
interstitial 

portal,  jaundice  in,  367 
Claudication,  intermittent,  427 
Club-foot,  varieties  of,  433 
"Cold  sores,"  19 


Colic,  biliary,  369 

intestinal,  393 

lead,  369 

renal,  369 
CoUargol-radiographs  in   kidney  dis- 
ease, 391 
Colon,  congenital  dilation  of,  375 

inflation      of,    in     diagonsis      of 
abdominal  tumors,  345 

palpation  of,  fluid  in,  345 
Coma,  alcoholic,  485 

causes  of,  483 

in  Stokes-Adams  syndrome,  486 

knee-jerk  in,  478 

postepileptic,  485 

sphincteric  reflexes  in,  481 
Compensation,  278 

cardiac,  establishment  of,  194 

cardiac,  failure  of,  195 

establishment  of,  203 

failing,  205,  207 

tests  of,  196 
Compression,  coma  in,  symptoms  of, 

48s 

of  lung,  283 
Concussion,  coma  in,  484 
Conjunctivitis,  causes  of,  14,  15 

following  arsenic,  15 

following  iodide  of  potash,  15 

with  hay  fever,  14 

with  measles,  14 

with  yellow  fever,  14 
Constipation,  378 

in  intestinal  obstruction,  377 

tongue  in,  23 
Contractures  following  atrophic  arth- 
ritis, 466 

hemiplegic,  hand  in,  51 

of  arm,  39 

of  the  interossei  and  lumbricales, 
claw  hand  in,  51 
Cornea,  16 

Corrigan  pulse, 103,  221,  230,  241 
Cough,   161,   196,  207,  258,  274,  283, 
285,  293,  302,  321 

with  sputa,  307 
Cranium,  size  and  shape,  5 
Cremasteric  reflex,  480 
Crepitation,  atelectatic,  277 


494 


INDEX 


Crepitus    in    monarticular    atrophic 
arthritis,  464 

in  perigastritis,  344 

in  perihepatitis,  344 

in  perisplenitis,  344 

in  peritonitis,  344 

peritoneal,  344 
Cretinism,  1 1 

lips  in,  19,  21 

teeth  in,  22 

tongue  in,  24 
"Croup,"  breathing  in,  76 
Curvature  of  spine,  34,  58,  59,  67 
Cyanosis,  57,  90,   196,  207,  235,  238, 
250,  278,  283 

causes  of,  91 

of  arm,  266 

of  intestinal  origin,  19 

of  lips,  19 

of  tongue,  23 
Cyst,  branchial,  34,  35 

hydatid,  365 

of  kidney,  389,  390 

of  mediastinum,  335 

pancreatic,  371 
Cystitis,  412 

urine  in,  396,  397,  398,  408 
Cystoscopy,  396 
Cytodiagnosis,  in  meningitis,  332 

of  pleural  effusion,  331 

technique  of,  331 

Dactylitis,  syphilitic,  55 

tuberculous,  55 
Debility,  285 

fibrillary  twitchings  in,  475 

mitral  stenosis  in,  217 

spleen  in,  387 
Deformities,  congenital,  of  heart,  250 

of  chest,  67 

of  hands,  51 
Degeneration,  reaction  of,  481 
Delirium  cordis,  116,  207,  249 
Dementia     paralytica,     degeneration 
of  handwriting  in,  482 

paralytica,  tongue  in,  23 
Dextrocardia,  83 
Diabetes,  acetone  breath  in,  22 

bronzed,  372 


Diabetes,  coma  in,  484 

dyspnoea  in,  73 

gangrene  of  toe  in,  435 

optic  neuritis  in,  17 

retinal  hemorrhage  in,  17 

ulcer  of  toe  in,  435 
Diaphragm,  movements  of,  70,  77-78 
Diarrhoea,  causes  of,  375 
Diastole,  181 

Dibothriocephalus  latus,  380 
Digitalis,  215 
Dilatation,  aortic,  231 

cardiac,  199 

of  aortic  arch,  219,  226 

of  heart,  84,  94,  261,  273 
Diphtheria,  tonsils  in,  27 

with  nasal  discharge,  18 
Dipping,  344,  363 
Displacement  of  apex  beat,  220 

of   cardiac  impulse,   see   Cardiac 
impulse 
Distomum,  Westermanni,  304 
Diverticulum  of  esophagus,  353 
"Double  shock  sound,"  213,  215 
Dropsy,  i,  207,  235 

in  cardiac  disease,  195 

of  pericardium,  255 
Drummond's  signs,  267 
Ductus  arteriosus,  persistence  of,  251 
Duodenal  ulcer,  360 
Dupuytren's  contraction,  56 
Duroziez's  sign,  224 
Dysentery,  chronic,  anemia  in,  447 
Dyspepsia,  clean  tongue  in,  23 
Dysphagia,  258 

Dyspnoea,  19,  196,  207,  235,  238,  258, 
275,  278,  283 

nose  in,  18 

varieties  of,  72,  73 

see  also  Breathing 
Dystrophy,  muscular  lordosis  in,  59 

Ear,  gouty  tophi  of,  472 
Echinococcus  of  pleura,  329 
Egophony,  164,  280,  321 
Electrical  reactions,  481 
Electrocardiograms,  113,  247 
Emaciation,  2,  350,  368 
Embolism,  312 


INDEX 


495 


Embolism  in  mitral  stenosis,  215 

septic,  238 
Embryocardia,  176 
Emphysema,  58,  64,  69,  75,  78,  275, 
277,  288,  296,  300 

atrophic  ("small-lunged"),  298 

breathing  in,  152 

complementary,  300 

expiration  in,  298 

interstitial,  299 

large-lunged,  296 

of  lung,  156 

percussion  signs  in,  297 

sub-cutaneous,  see  Interstitial 

vicarious,  284 

with  asthma,  299 

with  bronchitis,  299 

with  phthisis,  294 
Empyema,  70,  157 

interlobar,  259,  324,  325 

necessitatis,  272 

post-pneumonic,  281,  325 

sputa  in,  303 

tuberculous,  325 
Endaortitis,  231 

Endocarditis,     191,     232,     233,    260, 
278 

acute,  186 

aortic,  230 

chronic,  209 

fcetal,  250 

in  arthritis,  acute  infectious,  462 

rheumatic,  116,  218 

septic,  57 
Endometritis,  420 
Endothelioma,  329 
Enteritis,  stools  in,  379 
Eosinophilia,  450 
Epididymitis,  416 
Epigastric  pain,  350 

pulsation,  198 

reflexes,  480 

retraction,  83 
Epigastrium,  hernia  in,  342 

inspection  and  palpation  of,  350 

tenderness  in,  350 

tumor  of,  350 
Epilepsy,  coma  in,  485 

Jacksonian,  hands  in,  46,  47 


Epiphyses,  enlarged  in  rickets,  434 
Epiphysitis,  acute,  septic,  425 

chronic,  tuberculous,  425 
Epispadias,  415 
Epithelioma,  24 

of  ankle,  434 

of  back,  59 

of  nose,  19,  20 
Epulis,  25 
Equinus,  433 
Eruptions,  92 

of  forehead,  7 
Erysipelas,  oedema  of  lids  in,  14 
Erythromelalgia,  434 
Esbach's  test  for  albumin,  399 
Esophagus,  cancer  of,  353 

cardio-spasm  with  dilatation  of, 

353 
dilatation  of,  353 
diverticulum  of,  353 

Ewald's  test  meal,  355 

Exophthalmic     goitre,      see     Graves' 
disease 

Exostosis  of  thigh,  426 

Extrasy stoles,  118,  249 

Eyes,  14 

circles  under,  14 

in  aneurism,  266 

in  muscle  paralysis,  474 

oedema  of  lids,  causes  of,  14 

Face,  8-13 

after  vomiting,  1 2 

in  acromegalia,  8 

in  adenoids,  1 1 

in  alcoholism,  12 

in  cretinism,  11 

in  Graves'  disease,  12 

in  leprosy,  12 

in  myxoedema,  8,  11 

in  nephritis,  13 

in  paralysis  agitans,  11,  12 

in  phthisis,  12 

"mask-like,"  11,  12 

oedematous,  13 

spasms  of,  cause  of,  13 

swelling  of,  25 
Fallopian  tubes,  420 
Faradic  reaction  in  disease,  481 


496 


INDEX 


Fatigue,  degeneration  of  handwriting 

in,  482 
Fatty  metamorphosis  of  heart,  246 
Feces,  abriormal  ingredients  in,  379 

blood  in,  379 

color  of,  378 

gall-stones  in,  380 

microscopic  examination  of,  383 

mucus  in,  379 

odor  of,  378 

parasites'    eggs   in,   diagnosis  of, 
382 

parasites  in  types,  of,  380 

pus  in,  380 

tarry,  379 

weight  of,  378 
Feet,    hot,   in   myocarditis  in  arterio- 
sclerosis, 434 
Fehling's  test,  400 
Fermentation  in  cancer  of  stomach, 

360 
Fever,  2,  285 

causes  of  2,  3 

"continued,"  3 

crisis  in,  3 

determination  of,  3 

dilatation  of  pupils  in,  16 

emaciation  in,  2 

in  appendicitis,  376 

infectious,  nosebleed  in,  18 

in  intestinal  obstruction,  377 

"intermittent,"  3 

in  tonsillar  abscess,  28 

leucocyte  count  in,  450 

lysis  in,  3 

sordes  in,  24 

tongue  in,  23 

typhoid,  see  Typhoid  fever 

types  of,  3 
Fibrillary  twitchings,  475 
Fibro-myoma  of  uterus,  420 
Filariasis,  blood  in,  455 

parasites  in,  455 
Finger-ends,  tender,  57 
Fingers,  clubbed,  43,  53,  266 

in  heart  disease,  43 

in  lung  disease,  43 

in  pleural  disease,  43 
Fistulse,  branchial  congenital,  35 


Flipper-hand  in  atrophic  arthritis,  5 1 
Fluid,  free  in  abdomen,  tests  for,  345 

in  pleurisy,  321 
Fluoroscope,  268,  287 

use  of,  329 
Follicular  tonsillitis,  427,  428 
Fontanels,  6 

bulging,  6 

delayed  closure  of,  6 

depressed,  6 
Forehead,  bony  nodes  of,  8 

eruptions  of,  7 

scars  of,  7 
Foot,  433 

club-,  varieties  of,  433 

flat-,  433 
Fremitus,   tactile,  see  Tactile  fremitus 
Friction,  pericardial  253,  254 

pleural,  see  Pleural 
Frontal  sinusitis,  8 
Funnel  breast,  65 

Gait,  ataxic,  474 

in  paralysis  agitans,  474 

spastic,  45,  474 

toe-drop,  474 
Gall  bladder,  369 

bladder,  adhesions  about,  370 

bladder,  enlarged,  370 

bladder,  incidence  of  diseases  of, 
362 

-stones  in  feces,  380 
Galvanic  reaction  in  disease,  482 
Gangrene,  local,  in  Raynaud's  disease, 

55 

of  lung,  293,  333 

of  mouth,  26 

of  toes,  435 
Gas,  poisoning  by,  coma  in,  485 
Gastric  cancer,  see  Cancer 

contents,  see  Stomach  contents 

crises,  370 

diseases,  incidence  and  diagnosis 
of,  360 

disturbances,  mitral  stenosis  in, 
217 

fermentation,  breath  in,  22 

fermentation,  tongue  in,  23 

peristalsis,  351 


INDEX 


497 


Gastric  stasis,  361 

ulcer,  360 

ulcer,  malnutrition  in,  2 

ulcer,  tongue  in,  23 
Genitals,  female,  inspection  of,  418 

female,  lesions  of,  418 

female,  palpation  of,  418 

male,  415 
German  measles,  glands  in,  31 
Gland,  atrophy  of  thyroid,  33 

cancer  of  thyroid,  33 

cervical,  in  malignant  disease,  3  i 

cervical,  in  syphilis,  30 

cervical,  in  tuberculosis,  30 

•enlarged,   causes  of,    29,   31,  33, 

93 

enlarged,  in  mesentery,  349 

in  cancer,  3  i 

in  German  measles,  3  i 

inguinal,  in  syphilis,  424 

in  Hodgkin's  disease,  30 

in  lymphatic  leukaemia,  31 

in  mumps,  3  i 

in  tonsillitis,  30 

sarcoma  of,  31,  33 

see  also  Adenitis 
Glanders,  59 
Glottis,  obstruction  of,  74,  76 

spasm  of,  301 
Glucosuria,  400 

experimental,  401 

permanent,  401 
Goitre,  exophthalmic,  see  Graves'  dis- 
ease 

simple,  32 . 

with  exophthalmus,  12 
Gonorrhoea,  arthritis  in,  461 

balanitis  in,  416 

distended   bladder  in   spasm   of 
urethra  in,  410 

inguinal  glands  in,  424 

orchitis  in,  416 

with  epididymitis,  416 

with  frequent  micturition,  412 
Gout,  toes  in,  43  5 

tophi  in  arm,  41,  42 

tophi  in  ear,  472 

tophi  in  joints,  458 
Gouty  arthritis,  472 
32 


Gotity  arthritis,  destruction  of  bone 
in,  472 

arthritis,  X-ray  of  hand  in,  472 
Graves'  disease,  12,  32,  45,  248 

disease,  capillary  pulsation  in,  90 

disease,  expression  in,  12 

disease,  hands  in,  44 

disease,  heart  sounds  in,  173 

disease,  hypertrophy  in,  198 

disease,  pulse  in,  221 
Grocco's  sign,  319 
Groin,  424 

glands  in,  424 

hernia  in,  424 

psoas  abscess  in,  425 
Guaiac  test  of  stomach  contents,   356, 

380 
Gumboil,  25 
Gums,  24 

bismuth  line  in,  24 

bleeding,  25 

in  lead  poisoning,  24 

in  poisoning  by  mercury,  24 

in  poisonirig  by  potassic  iodide, 
24 

in  scurvy,  25 

sordes  of,  24 

spongy,  25 

suppuration  of,  25 
Giinzburg's  reagent,  356 

H^EMATEMESis  in  portal  obstruction, 

366 
Hematocele,  417 
Haematoma,    infected,  of  belly  wall, 

342 
Hsematuria,  385,  397 

causes  of,  413 
Hjemoglobin,  tests  for,  19,  437 
Hsemopericardium,  256 
Haemophilia,  nosebleed  in,  18 
Hsemophilic  arthritis,  472 
Haemoptysis,  196 

causes  of,  285,  303,  304 

in  mitral  stenosis,  215 
Haemorrhage,  see  Hemorrhage 
Hair,  abnormal  loss  of,  7 

in  myxoedema,  8 

in  rachitis,  6 


498 


INDEX 


Hair,  in  syphilis,  7 

parasites  in,  7 
Hands,  43 

choreiform,  movements  of,  47 

deformities  of,  51 

evidence  of  occupation,  43 

examination  of,  43,  44 

in  alcoholism,  44 

in  atrophic  arthritis,  54 

in  cardiac  weakness,  44 

in  carphologia,  44 

in  chorea,  47 

in    contractures  following  hemi- 
plegia, 51 

in  Graves'  disease,  44 

in  Jacksonian  epilepsy,  46,  47 

in  rayx oedema,  51,  52 

in  paralysis  of  median  or  ulnar 
nerves,  51 

in  progressive  muscular  atrophy, 

51 
in  subsultus  tendinum,  44 
in  typhoid  fever,  44 
moisture  of,  44 
spasms  of,  47 
temperature  of,  44 
tremor  of,  45 

Handwriting,  degeneration  of,  482 

Hang-nails,  56 

Hare-lip,  21 

Harrison's  groove,  65 

Hay  fever  with  conjunctivitis,  14 

Head,  abnormalities  of,  5 
open  areas  of,  5 
shaking  of,  .13,  219 

Heart,    see    also    Cardiac,    Murmurs, 
Regurgitation,   Stenosis, 
Breathing 
action,  accelerated,  116 
apex    impulse,  79,  80,  81,  94,  95, 
181,  198,  220,  243,  258,  260, 
309,  322 
auscultation  of,  167,  197 
beat,  alternation  of,  119 
beat,  coupling  of,  119,  215 
beat,  "dropped,"  114,  115 
beat  in  mitral  stenosis,  213 
beat,  irregular,  245 
beat,  premature,  118,  119 


Heart,  block,  113,  250 

block,  "dropped  beats,"  114,  115 
bradycardia,  248 
characteristics  of  dilatation,  199, 

200 
chronic  dilatation  of,  199 
compensation,  194 
congenital  raalformations,  250 
cycle,  systole  and  diastole,   180, 

181 
dilatation  of,  84,   199,  200,  261, 

273 
disease,    congestion   of   liver   in, 

364 
disease,  emphysema  in,  19 
disease,  methaemoglobinsemia,  19 
disease,  pneumonia  in,  19 
disease,  poisoning  in,  19 
diseases  of,  191 
dislocation  of,  309,  319,  323 
enlarged,  70,  129,  204,  207,  217, 

2i9>  23s 
fatty  metamorphosis,  246 
hypertrophy  of,  81,  82,  219,  252, 

260,  261,  303 
impulse,  79,  81,  95 
in  aortic  aneurism,  266 
in  aortic  regurgitation,   218—226 
in  combined  lesions,  239-242 
in  mitral  regurgitation,  201—209 
in  mitral  stenosis,  209-218 
in  myocarditis,  243 
in  pericarditis,  253 
pleural  effusion,  259 
in  pneumothorax,  309 
in  tricuspid  regurgitation,  208 
irregular  action  of ,  213,  222,  247, 

250 
lips  in  disease  of,  19 
mitral  insufficiency,  202 
murmurs,  see  Murmurs 
.  over-distention  of,  86 
palpation  of,  81,  197,  200,  221 
palpitation  of,  249,  250,  see  also 

Arrhythm.ia 
parietal  diseases  of,  243-247 
rapid,  247  see  Tachycardia 
situation  of  apex  impulse,  62,  68 
slow,  248,  see  Bradycardia 


INDEX 


499 


Heart,  sounds,  167,  168,  245,  253-258 
sounds,  accentuation  of,  172-174 
sounds,  arterial,  177 
sounds,  doubling  of,  176 
sounds,  first,    168-170,    171,    175 
sounds,  metallic,  176 
sounds,  muffled,  176,  177 
sounds,  modification  in,  170 
sounds,  normal,  168 
sounds,  qualities  of,  169-170 
sounds,     reduplication    of,     176, 

213 
sounds,    second,    168,    171,    172, 

173,  175 

sounds,  third,  170 

sounds,  weakening  of,  174 

stenosis,  191 

tachycardia,  247 

"tobacco,"  218 

"valve  areas,"  62 

valves,  position  of,  167 

valvular  incompetence,  192 

valvular  lesions  of,  191 

wall,  244,  246 

wall,  weakened,  191 

weakness,  243 

weakened,  244 
Heberden's  nodes,  54,  457,  467 
Hemianaesthesia,  477 
Hemiplegia,  215,  474 

atrophy  of  arm  in,  39 

hands  in,  51 

paralysis  of  leg  in,  428 
Hemorrhage,  anemia  in,  447 

in  retina,  17 

pulmonary,  285 

tendency  of,  in  jaundice,  367 
Hemorrhoids,  414 
Hepatic  abscess,  symptoms  in,  348 
Hepatization,  277 
Hernia,  epigastric,  342 

of  intestine,  312 

of  scrotum,  417 

umbilical,  342 
Herpes  labialis,  19-20,  482 

zoster,  482 
"  Herzenstoss,"  81 

Hip-joint,   hypertrophic   arthritis  of, 
58,  467 


Hip-joint,      hypertrophic       arthritis, 
morbus  coxae  senilis,  467 

limitation  of  motion  of,    58,  458, 
461 

psoas-spasm  of,  458 
Hirschsprung's  disease,  375 
Hoarseness,  285 
Hodgkin's  disease,  334,  389 

disease,  glands  in,  30,  93 

disease,  oedema  of  arm  in,  40 
Hook-worm,  382 
Housemaid's  knee,  429 
Hydatid  disease,  liver  in,  365 
Hydrocele,  417 

of  scrotum,  417 
Hydrocephalus,  head  in,  5 
Hydronephrosis,  390 
Hydropericardium,  255 
Hydrothorax,  155,  308 
Hymen,  imperforate,  419 
Hyperacidity,  gastric,  361 
Hypersesthesia,  tests  of,  477 
Hyperchlorhydria,  pain  in,  370 
Hypernephroma,  390 
Hyperresonance,  297,  300,  320 
Hypertension,  vascular,  nosebleed  in, 

18 
Hypertrophic  arthritis,   see  Arthritis 
Hypertrophy,  cardiac  impulse  in,  82, 
84 

cardiac,  causes  of,  196 

cardiac,  results,  197 

of  heart,  81,   94,   194,    195,   219, 
252,  260,  261,  303 

of  left  ventricle,  197,  217 

of  lung,  308 

of  right  ventricle,    198,   233,   238 
Hypoacidity  of  stomach,  361 
Hypostatic  penumonia,  337 
Hysteria,  45,  106 

anaesthesia  in,  477 

atrophy  in,  39 

breathing  in,  77 

coma  in,  485 

contractures  of  arm  in,  39 

hemianagsthesia  in,  477 

hypersesthesia  in,  477 

paralysis  in,  428,  429,  474 

ptosis  in,  16 


560 


INDEX 


Hysteria,  spasms  in,  14 
temperature  in,  2 

Idiocy,  mouth  in,  19 

Incidence  of  diseases  of  the  bladder, 
410 
of   diseases   of   gall-bladder   and 

bile  ducts,  362 
of  diseases  of  the  intestine,  373 
of  diseases  of  the  kidney,  389 
of  diseases  of  the  liver,  361 
of  diseases  of  the  pancreas,  372 
of  diseases  of  the  stomach,   360 
of  joint  lesions,  472 
of  thigh  disease,  425 
of  thigh  tumors,  426 

Indicanuria,  402 

Indigestion,  285 

Infancy,  examination  of  chest  in,  64, 
6s 
jaundice  in,  15 

Infantile  atrophy,  malnutrition  in,  2 

Infections,  106,  243,  347 
acute  chills  in,  3 
leucocytosis  in,  449 
lymphocytosis  in,  449 
pneumococcus,  277 
pulse  in,  103 
symptoms,  368 

Influenza,  18,  243,  275 

with  conjunctivitis,  14 

Insomnia,  2 

Inspection  in  aneurism,  263 

in  aortic  regurgitation,  219 

in  croupous  pneumonia,  278 

of  abnormal  thoracic  pulsations, 

64 
of  apex  beat,  79 
of  cardiac  movements,  7  9 
deformities  of  chest,  62 
of  head  and  face,  5 
of  peripheral  vessels,  86 
of  respiratory  movements,  70 
of  skin  and  mucous  membranes, 

90 
of  thorax,  64 

Insufficiency,  aortic,  216 
mitral,  226,  232 
myocardial,  116 


Interlobar  empyema,  see  Empyema 
Intestinal  colic,  393 

contents,  examination  of,  378 

obstruction,  371 

obstruction,  acute    and   chronic, 

377 
obstruction  by  gall-stones,  371 
obstruction,  causes  of,  377 
obstruction,  chronic  visible  peris- 
talsis in,  377 
obstruction,  distention  in,  374 
obstruction,    physical    signs    in, 

377 
obstruction,  tumor  in,  377 
parasites,  380 

parasites,  anemia  from,  447 
parasites,    diagnosis    of    eggs   of, 

382 
parasites,    eosinophilia    due     to,- 

450 
parasites,   relative  frequency  of, 

384 
tenderness,  374 
tenesmus,  374 
Intestines,  diseases  of,  373 

diseases  of,   constitutional  mani- 
festations, 373 
gaseous  distention  in,  374 
hernia  of,  312 
Intussusception,  379 
Iritis  with  irregular  outline  of  pupil, 

16 
Ischiorectal  abscess,  414 
Itching  in  jaundice,  15 

Jacksonian  epilepsy,  46 

epilepsy,  spasms  of  hand,  causes 
46 
Jaundice,  15,  90,  92,  364 

catarrhal,  367 

causes  of,  15,  366 

congenital,  368 

diagnosis  of  cause,  367 

in  biliary  cirrhosis,  368 

in  cancerous    obstruction  of  gall 
duct,  367 

in  cholelithiasis,  367 

in  portal  cirrhosis,  367 

in  syphilis,  15,  368 


INDEX 


501 


Jaundice  in  Weil's  disease,  368 

itching  in,  15 

mental  depression  in,  15 

of  new-born,  367 

of  tongue,  23 

results  of,  on  body,  367 

secondary,  in  septicemia,  368 

slow  pulse  in,  15 

with  bile,  15 

with  hepatic  cirrhosis,  15 

with  obstruction  by  stone,  15 

with  syphilis,  15 

with  toxaemia,  15,  367 

with    tumors     obstructing    bile- 
ducts,  15 
Jaw,  in  acromegalia,  8 

-jerk,  test  for,  480 
Joints,  ankylosis  of,  460 

bony  outgrowths,  457 

Charcot's,  464 

chronic  diseases  of,  knee-jerks  in, 

477 
creaking  in,  456,  460 
crepitus  in,  456,  460 
diseases  of,  460 
enlarged,  457 
examination  of,  456 
excessive  motion  in,  456,  460 
fluctuation  in,  457 
free  bodies  in,  456,  460 
gouty  deposits  in,  458 
inspection  of,  456 
irregularities  of  contour,  456 
lesions  of,  relative  frequency  of, 

472 
neuropathic,  464 
pain  in,  456 
palpation  of,  456 
radioscopy  of,  457 
sacro-iliac,  hypertrophic  arthritis 

of,  57 
scaro-iliac,  tuberculosis  of,  57 
tests  of  limitation  of  motion,  456, 

458 
see  also  Arthritis,  Hip-joint 

Keratitis,  syphilitic,  cornea  in,  16 

Kemig's  sign,  480 

Kidney,  abscess  of,  390,  391 


Kidney,  contracted,  urine  in,  409 

cyst  of,  389,  390 

cyst  of,  distinguished  from  hydro- 
nephrosis, 390 

diseases  of,  389-409 

diseases,  statistics  of,  389 

diseases,  urine  in,  393 

diseases,  vocal  and  constitutional 
evidence  of,  393 

displaced,  movable,  392 

floating,  369,  392 

floating,  tenderness  in,  390 

malignant  disease  of,  390 

pus  in,  396 

tumors  of,  390 

see  also  Renal 
Knee,  housemaid's,  429 

tuberculosis      of,      distinguished 
from  sarcoma,  426 

-jerk,  477 

-jerk,  absence  of,  478 

-jerk,  increased,  478 
Knock-knee,  429 
Koplik's  spots  in  measles,  25 
Koranyi's  sign,  319 
KorotkofE's  method,  no 
Kyphosis,  58 

in  emphysema,  58 

in  hypertrophic  arthritis,  58 

in  Paget's  disease,  58 

in  Pott's  disease,  58 

in  rickets,  58 

Lactic  acid  in  gastric  contents,  357 

Lamblia  intestinalis,  380 

Lavage  of  stomach,  355 

Lead  colic,  pain  in,  370 
line,  24 
poisoning,  see  Plunibism 

Legs,  bowed,  429 

chronic  ulcers  of,  430 
in  hysteria,  428 
in  multiple  sclerosis,  428 
in  spastic  paraplegia,  428 
in  tabes  dorsalis,  428 
malpositions  of,  460,  461,  462 
oedema  of,  causes  of,  431 
osteomyelitis  in,  431 
paralysis  of,  causes  of,  428 


502 


INDEX 


Legs,    paralysis   of,   differential  diag- 
nosis in,  428 

sarcoma  of,  431 

syphilitic  periostitis  of,  430 

tenderness,  in  neuritis,  432 

tenderness,  in  trichiniasis,  432 

varicose  veins  of,  430 
Leprosy,  56 

face  in,  12 
Leucocyte  chart,  450 

count,  444,  445 

count  in  general  peritonitis,  347 
Leucocytosis,  449 

diagnostic  value  of,  449 

in  appendicitis,  376 

occurrence  of,  449 
Leukaemia,  70 

liver  in,  365 

lymphatic,  blood  in,  450,  451 

lymphatic,  glands  in,  3 1 

myelogenous,  blood  in,  450,  451 

nosebleed  in,  18 

percussion  in,  131 

spleen  in,  389 
Leukoplakia  buccalis,  24 
Line,  mid-axillary,  62 
Lineae  albicantes,  339 
Lingula  pulmonalis,  295 
Lips,  19 

angioneurotic  oedema  of,  20,  21 

cancer  of,  20 

chancre  of,  20 

cracks  or  fissures  in,  19 

in  cretinism,  19,  21 

in  heart  disease,  19 

in  myxoedema,  19,  21 

pallor  of,  19 

parted,  19 
Litmus-test,  398 
Litten's  sign,    77,    78,    134,    286,    287, 

296,  309,  324 
Liver,  207,  323,  361—369 

abscess  of,  348 

abscess  of,  distinguished  from 
syphilis  or  malignant  dis- 
ease, 365 

acute  yellow  atrophy  of,  366 

amyloid,  365 

atrophy  of,  365 


Liver,  cancer  of,  364 

cirrhosis  of,  70,  190,  261,  364,  388 
cirrhosis  of,  anemia  in,  447 
cirrhosis  of,  coma  in,  484 
cirrhosis  of,    oedema  of  legs  in, 

431 
disease,    cerebral    symptoms   in, 

369 
disease,  incidence  of,  361 
disease,    portal    obstruction    in. 

365 

enlargement,  328,  362 

enlargement,  causes  of,  363 

fatty,  364 

growth  of,  in  cancer,  364 

hydatid  disease  of,  365 

in  pneumothorax,  309 

leuksemic,  365 

malignant  disease  of,  symptoms 
in,  364 

percussion  of,  130 

pulsation  in,  234 

syphilis  of,  distinguished  from 
cirrhosis  or  malignant  dis- 
ease, 364 

tumor  of,  343 

see  also  Gall  bladder,  Jaundice 
Lordosis,  59 

in  muscular  dystrophy,  59 

in  tuberculosis,  59 

with  abdominal  tumors,  59 

with  pregnancy,  59 
Ludwig,  angle  of,  296 
Lumbago,  57 
Lung,  abscess  of,  21,  303,  333 

adventitious  sounds,  see  Rdles 

anatomy  of,  61 

atelectasis  of,  328 

auscultation  of,  147 

cancer  of,  69,  348 

cirrhosis  of,  68,  302 

collapse  of,  see  Atelectasis 

compression  of,  283 

condensation  of,  268 

congestion  of,  see  (Edema 

consolidation  of,  see  Solidifica- 
tion 

diseases  of,  274—295 

emphysema  of ,  156,  296—300 


INDEX 


503 


Lung  fever,  283 

fibroid  disease  of,  83,  273,  294 

fistula  sound,  166 

gangrene  of,  22,  293,  333 

hypertrophy  of,  308 

niaUgnant  disease  of,  69,  348 

miliary  tuberculosis  of,  295 

neoplasms  of,  334 

oedema  of,  276,  336 

palpation  of,  96 

percussion  of,  134 

phthisis,  285-295  see  also  Titber- 

cidosisof  the  lungs 
pneumonia,  277,  283 
rales,  in  disease  of,  158,  274 
reflex,  336 

reflex  in  percussion,  136 
resolution  of,  281 
retraction  of,  84,  273 
Rontgen    ray     examination     of, 

325.  333 

sarcoma  of,  40,  334 

solidification  of,    277,    279,    283. 
284,  288,  290 

syphilis  of,  301 

tuberculosis     of,      285-295 
Lupus  erythematosus,  nose  in,  18 
Lymphangiectasis,  filarial,  425 
Lymphatic  leukgemia,  blood  in,  450 

leuksemia,  glands  in,  3  i 
Lymphocytosis,  450 

in  acute  sepsis,  450 

in  debility,  450 

in  whooping  cough,  450 

Mackenzie's  polygraph,  115 
Malaria,  anemia  in,  447 

chills  in,  3 

jaundice  in,  15,  367 

parasites  in,  453 

splenic,  enlargement  in,  387 
Malignant  disease,  anemia  in,  447 

disease,  glands  in,  31 

disease,  toxemia  in,  449 

disease,  see  also  Cancer,  Epithe- 
lioma, Sarcoma,  Myelom,ata 
Malnutrition,  2 

emaciation  in,  2 

in  anorexia  nervosa,  2 


Malnutrition  in  chronic  diarrhoea,  2 
in  chronic  dyspepsia,  2 
in  diabetes,  2 
in  gastric  cancer,  2 
in  gastric  dilatation,  2 
in  gastric  ulcer,  2 
in  infantile  atrophies,  2 
in  oesophageal  stricture,  2 
Massage,  leucocytosis  in,  449 
Mast  cells  in  blood,  443 
Measles,  conjunctivitis  in,  14 
German,  glands  in,  3 1 
Koplik's  spots  in,  25 
mouth  eruption  in,  2  5 
oedema  of  face  in,  10,  14 
Mediastinitis,  chronic,  260 

fibrous,  84 
Mediastinum,  cysts  of,  334 
neoplasms  of,  36,  334 
sarcoma  of,  334 
Megaloblasts,  442 
Melsena,  379 

Membranes,  mucous,  inspection  of,  90 
^leningitis,  bulging  of  fontanels  in,  6 
cytodiagnosis  in,  332 
leucocytosis  in,  449 
tuberculous,  breathing  in,  76 
tuberculous,  optic  neuritis  in,   17 
Mensuration,  61 

Mental  depression  in  jaundice,  15 
Meralgia  paraesthetica,  427 
Mesentery,  enlarged  glands  of,  349 

thrombosis  of,  349 
Metallic  tinkle,  165,  310 
Metatarsalgia,  436 
Methsmoglobinsemia,  lips  in,  19 
Microcephalia,  6 
Migraine,  aphasia  in,  482 
Mitral  disease,  99 

disease,  double,  240,  241 
stenosis,  see  Stenosis,  mitral 
Monoplegia,  474 

leg  in,  428 
Morbus  coxffi  senihs,  467 
Morton's  disease,  436 
Morvan's  disease,  56 
Motion,  disorders  of,  473 
Mouth,  eruptions  of,  25 
fissures  of,  19 


504 


INDEX 


Mouth,  gangrene  of,  26 

herpes  of,  20 

in  Addison's  disease,  26 

in  adenoids,  19 

in  cretinism,  19,  21 

in  dyspncea,  19 

in  idiocy,  19 

mucous  patches  in,  25,  26 

pigmentations  of,  26 

syphiHtic  ulcers  of,  20 
Movements,  respiratory,  70 
Mucus  in  feces,  379 
Multiple  sclerosis,  478 

sclerosis,  intestinal  tumors  of,  45 

sclerosis,  knee-jerk  in,  479 

sclerosis,  nystagmus  in,  16,  45 

sclerosis,  paraplegia  in,  428 

sclerosis,  spastic  gait  in,  45 

sclerosis,  speech  in,  45 

sclerosis,  tremor  in,  45 
Mumps,  glands  in,  31 

orchitis  in,  416 
Murmurs,  aortic,  183,  209 

aortic  regurgitant,  179 

arterial,  189,  190 

Austin  Flint,  215,  216,  226 

cardiac,  178 

cardio-pulmonary,  225 

cardio-respiratory,  188,  189,  209 

diagnostic  interpretation  of,  182, 

183 
diastolic,  180,  182,  185,  223 
disappearance  of,  186 
functional,    185,    186,    187,    188, 

203,  208,  231,  236,  238,  239 
functional,  cause  of,  186 
hffimic,  see  Functional 
"hour-glass,"  183 
in  aortic  aneurism,  267 
in  mitral  regurgitation,  203,  204 
in  mitral  stenosis,  211,  213,  214 
intensity  of,  183,  184 
intracardiac,  255 
in  tricuspid  stenosis,  237 
length  of,  185 
metamorphosis  of,  186 
musical,  204 
of  Flint,  215,  216,  226 
organic,  186,  188 


Murmurs,  position  of,  181,  182 

presystolic,  180,  237 

presystolic  in  tricuspid  stenosis, 
215,  216,  217 

quality  of,  184 

significance    in    enlarged    heart, 
217 

significance  of,  185 

significance    of    precordial,    239, 
240 

systolic,  180,  182,  187,  203,  251 

systolic,  in   aortic   stenosis,  228, 
229 

terminology  of,  178 

time  of,  180 

transmission  of,  181 

venous,  189 
Muscle  sounds,  276,  315 
Muscular  dystrophy,  lordosis  in,   15 
Myelitis,  acute,  bedsores  in,  483 

knee-jerks  in,  479 

reaction  of  degeneration  in,  482 

sexual  power  in,  481 

transverse  or  diffuse,  paraplegia 
in,  428 
Myelomata  of  skull,  5,  6 
Myocarditis,  acute,  243 

auscultation  in,  245 

causes  of,  245 

chronic  heart  sounds  in,  171 

chronic  interstitial,  244 

in  acute  rheumatism,  244 

hot  feet  in,  434 
Myoma  of  uterus,  420 
Mjrxoedema,  8,  11 

face  in,  8,11 

hands  in,  51,52 

increase  in  weight  in,  i 

infantile  form,  10 

lips  in,  19,  21 

loss  of  hair  in,  7 

nose  in,   17 

tongue  in,  24 

Nails,  56 

capillary  pulse,  57 
changes,  in  hemiplegia,  56 
changes,  in  myx oedema,  56, 
changes,  in  neuritis,  56 


INDEX 


505 


Nails,  changes,  in  syringomyelia,  56 

grooved,  56 

in  anemia,  57 

incurvation  of,  57 

indolent  sores  around,  56 
Neck,  29 

abscess  in,  32 

actinomycosis  of,  35 

diseases  of,  29-36 

in  emphysema,  29 

in  paralysis  agitans,  1 1 

oedema  of,  36 

scars  of,  32 
Necrosis,  ansesthetic,  in  leprosy,  56 

of  bone,  in  tuberculous  arthritis, 
461 

of  rib,  99 
Nephritis,  acute,  397 

acute,  urine  in,  408 

albuminuria  in,  400 

chronic,  106,  iii 

chronic   glomerular,    anemia    in, 

447 

chronic  glomerular,  urine  in,  408 

coma  in,  484 

face  in,  13 

glomerular,  polyuria  in,  394 

heart  sounds  in,  174 

oedema  of  legs  in,  43  i 

oedema  of  lids  in,  14 

parenchymatous,  408 

retinal  hemorrhage  in,  17 
Nervous  system,  473-486 
Neuralgia,  intercostal,  76 

red,  of  extremities,  434 
Neurasthenia,  fibrillary  twitchings  in, 

475 
ptosis  in,  16 
pulse  in,  221 
Neuritis  after  anesthesia,  37 
alcoholic,  38 
atrophy  of  arm  in,  39 
due  to  pressure,  3  7 
lead,  38 
multiple,  39 
oedema  of  legs  in,  43  i 
obstetrical,  paralysis  in,  38 
optic,  17 
paralysis  of  arm  in,  37,  38,  39 


Neuritis,  paralysis  of  leg  in,  428 

peripheral,  knee-jerk  in,  478,  479 

postdiphtheritic,    pharyngeal  re- 
flexes in,  29 

pressure,  test  for,  37 

toxic,  paralysis  in,  38 
Neuroses,  functional,  247 

hysterical,  39 

traumatic,  39 
Nodes,  Heberden's,  54,  457,  467 

in  back,  59 

in  gouty  arthritis,  472 

on  forehead,  8 

syphilitic,  40 

sino-auricular,  113,  114 
Noma,  26 

Normoblasts  in  blood,  442 
Nose,  18 

discharge  from,  18 

epithelioma  of,  19,  20 

falling  in  of  bridge  of,  18 

hemorrhage     of     mucous     mem- 
branes, 18 

in  acne  rosacea,  18 

in  acromegalia,  8,  17 

in  adenoid  growths,   18 

in  alcoholism,  17,  18 

in  lupus  erythematosus,  18 

in  myxoedema,  1 7 

in  syphilis,  18 

in  tuberculosis,  19 

local  disease  of,  19 

size  and  shape  of,  17 
Nosebleed,  18 
Nostrils,  18 
Nystagmus,  16,  45 

Obesity,  i 

Obstruction,  intestinal,  see  Intestinal 

laryngeal,  76 

portal,  366 
Ocular  motions,   16 
CEdema,  91,  247,  266 

angioneurotic,  14,  432 

angioneurotic  of  lips,  20 

in  anaemia,  43  i 

in  deficient  local  circulation,  432 

in  flat-foot,  432 

in  heart  disease,  195 


506 


INDEX 


CEdema  in  hemiplegia,  432 
in  inflammation,  432 
in  nephritis,  43  i 
in  neuritis,  432      ■ 
in  obesity,  432 
in  pressure,  432 
in  thrombosis,  432 
in  uncompensated  heart  lesions, 

431 

in  varicose  veins,  432 

of  arm,  causes  of,  40 

of  eyelids,  causes  of,  14 

of  face,  13 

of  legs,  causes  of,  43 1 

of  lungs,  207,  276,  303,  336 

of  neck,  36 
Oliguria,  394 
Opium-poisoning,  coma  in,  485 

-poisoning,  shaking  of  head  in,  13 
Optic  atrophy,  17 
Orchitis  acute,  416 
Orthopncea,  207 
Osteitis  deformans,  5,  427 
Osteoarthritis,  467 
Osteo-arthropathy,  43,  52,  53 

arm  in,  43 
Osteoma  or  exostosis  of  thigh,  426 
Osteomyelitis,  acute,  septic,  425 

chronic,  tuberculous,  425 

tibia  in,  431 
Ovarian  disease,  diagnosis  of,  421 
Ovaries,  cyst  of,  with  twisted  pedicle, 
421 

tumors  of,  421 
Ovaritis,  421 
Oxaluria,  407 
Oxyuris  vermicularis,  380 

"Pace-maker,"  114 
Paget's  disease,  5,  58,  427 

disease,  arm  in,  42 
Pain,  epigastric,  350  \ 

hepatic,  348,  362 

in  appendicitis,  376 

in  arm,  266 

in  intestinal  disease,  373 

in  joints,  456 

in  peritonitis,  346 

in  sacro-iliac  joint,  57,  58 


Pain  in  thorax,  156 

in  tonsillar  abscess,  28 

muscular,  320 

nerve,  in  hypertrophic  arthritis, 
469 

over  sternum,  274 

precordial,  196 

renal,  392 
Palate,  perforation  of  soft,  29 
Pallor,  92 

causes  of,  92 

in  phthisis,  12 
Palpation,  94—105 

and  dipping,  344 

and  friction,  98 

in  aneurism,  263 

in  aortic  regurgitation,  221 

in  croupous  pneumonia,  278 

in  myxoedema,  1 1 

of  abdomen,  methods  of,  338 

of  apex  beat,  94 

of  heart,  81,  197,  200 

of  normal  abdomen,  341 

of  rales,  99 

of  the  pulse,  100 

of  thrills,  95 

of  voice  vibrations,  96 
Palpitation,  249 
Pancreas,  cancer  of,  diagnosis  of,  371 

cyst  of,  371 

diseases  of,  371 

diseases  of,  diabetes  in,  372 

diseases  of,  incidence  of,  372 

diseases  of,  stools  in,  371 

diseases  of,  urine  in,  371 
Paraesthesia,  477 

in  neuritis,  38 
Paralysis  agitans,  11,  12,  45,  46 

agitans,  gait  in,  474 

agitans,  shaking  head  in,  13 

bulbar,  23 

cerebral,  knee-jerk  in,  478,  479 

congenital,      choreiform     move- 
ments in,  50 

facial,  tongue  in,  23 

in   acute   anterior  poliomyelitis, 
37.  428 

in  chorea,  428 

in  diseases  of  spinal  cord,  428 


INDEX 


507 


Paralysis,  infantile  cerebral,  athetosis 
in,  so 
in  hemiplegia,  49,  428 
in  hysteria,  39,  428,  429,  474 
in  lead-poisoning,  37,  38,  428 
in  myelitis,  428 
in  neuritis,  37,  428 
in  tabes,  428 
in  toxic  neuritis,  428 
in  traumatic  neurosis,  37 
of  arm,  37 
of  brain,  474 
of  cord,  474 
of  cranial  nerve,  474 
of  dorsal  or  abdominal  muscles, 

59 

of  legs,  428 

of    interossei     and     lumbricales, 
claw-hand  in,  51 

of  muscles  of  respiration,  156 

of  peripheral  nerve,  474 

pharyngeal  reflexes  in,  29 

pupils  in,  16 

serratus,  scapula  in,  60 

with  contraction  of  pupil,  15 
Paraphimosis,  416 
Paraplegia,  474 

paralysis  of  leg  in,  428    ■ 

spastic,  428,  479 
Parasites,   animal,     diseases    due    to, 

450 

in  feces,  380 

in  hair,  7 

intestinal,  eggs  of,  382 

malarial,  453 
Paravertebral  triangle,  319 
Paresis,  474 
Paronychia,  56 
Parotid  gland,  cancer  of,  31 

gland,  enlargement  of,  3  i 
Parturition,  leucocytosis  in,  449 
Patella,  floating  of,  test  for,  457 
Pectus  carinatum,  65 
Pediculi  in  hair,  7 
Penis,  415 

cancer  of,  416 

chancre  of,  415 

chancroid  of,  416 

discharge  from,  415 


Penis,  inflammation  of  glands  of,  416 

malformations  of,  416 
Peptic  ulcer,  360,  369 
Percussion,  auscultatory,  126 

dull  areas  in,  129,  131,  133 

force  of,  124,  130 

importance  of  symmetrical,  132 

in  aneurism,  267 

in  aortic  regurgitation,  222 

in  croupous  pneumonia,  278,  279 

in  enlarged  heart,  130 

lung  reflex  in,  136 

mediate  and  immediate,  120 

note,  modifications  of,  133 

of  heart,  200 

of  lung  borders,  134 

palpatory,  127,  128 

resonance,  amphoric,  135 

resonance,  cracked-pot,  134,  275, 

293 
resonance,  dull,  129 
resonance  of  chest,   128 
resonance,  tympanitic,  131,  309, 

317 

resonance,  varieties  of,    135 

signs  in  phthisis,  293 

technique  of,  120,  136 
Peribronchitis,  tuberculous,  acute,  295 
Pericardial  friction,  see  Pericarditis 
Pericarditis,  278 

dry,  253,  254 

efEu-sion,  distinguished  from  pleu- 
ritic, 259 

fibrinous,  253-254 

friction    in,    98,    236,    237,    253, 

254 
tricuspid  stenosis  after,  217 
with  effusion,  253 
Pericardium  adherent,  84,  203,  260 

diseases  of,  253-262 
Perihepatitis,  362 
Perinephritic  abscess,  59,  391 

abscess,  psoas  spasm  in,  462 
Perineum,  ruptured,  419 
Periostitis,  syphilitic,  430 
Peripheral   nerve   lesions,    hemianass- 
thesia  in,  477 
nerve  lesions,    hyperaesthesia   in, 
477 


508 


INDEX 


Peripheral   neuritis,    reaction   of    de- 
generation in,  482 
Peristalsis,  visible  gastric,  351 

visible,  in  intestinal  obstruction, 

377 
Peritoneum,  cancer  of,  348 

diseases  of,  346 

tuberculosis  of,  348 
Peritonitis,  causes  of,  347 

general,  347 

local,  346 

respiratory  movements  of  belly- 
in,  339 

with  thickening  or  inflammation 
of  navel,  343 
Peri-urethral  abscess,  416 
Pernicious  anemia,  see  Anemia. 
Pharyngeal  reflexes  in  alcoholism,  29 

reflexes  in  paralysis,  29 

reflexes  in  postdiphtheritic  neuri- 
tis, 29 
Pharyngitis,  27 
Pharynx,  26 

eruptions  of,  27 

examination  of,  27 
Phimosis,  416 
Phlebitis,  427 
Phlebograms,  113,  247 
Photophobia,  16 
Phrenic  wave,  77 
Phthisis,  78,  99,  285-295,  301,  314 

advanced,  290 

advanced,  sputa  in,  303 

bronchial  breathing  in,  157 

chest  in,  65,  66,  67,  68 

cracked-pot  resonance  in,  134 

face  in,  12 

fibroid,  83,  84,  273,  294 

fibroid    with  pleural  thickening, 
291 

pulse  in,  221 

pupils  in,  16 

sweating  in,  4 

with  pleural  thickening,  294 

see  also  Tuberculosis  of  lung 
Pigmentation  in  Addison's  disease,  26 

in  negroes,  26 
Pin-worm,  in  feces,  380 
Platelets  in  blood,  444 


Pleura,  cancer  of,  329 

diseases  of,  308—332 

echinococcus  of,  329 
Pleural  adhesions,  78 

cavity,  fluid  in,  155 

effusion,    78,    82,    86,    157,    278, 
280,  285,  308,  309,  311,  312, 

315 
effusion,  absorption  of,  324 
effusion,  cytodiagnosis  in,  331 
effusion,  distinguished  from  peri- 
cardial, 259 
effusion,  distinguished  from  pneu- 
monia, 282,  327 
effusion,  egophony  in,  164 
effusion,  encapsulated,  326 
effusion,  percussion  signs  in,  315 
fluid,  examination  of,  330 
friction,  98,  161,  278,  308,  314 
friction,    distinction    from    peri- 
cardial friction,  254,  255 
friction,  seat  of,  162 
thickening,    291,    294,    316,    325, 
326 
Pleurisy,  68,  83,  99,  260,  308-332 
auscultatory  signs  in,  323 
breathing  in,  76 
clubbed  fingers  with,  53 
dry,  314 

Grocco's  sign  in,  319 
plastic,  314 
pulsating,  86,  327 
purulent,  86 

sub-crepitant  rales  in,  161 
Plumbism,  39 

anemia  in,  447 
lead  line  in,  24 
paralysis  in,  37,  38,  428 
respiratory  movements  of  belly 

in,  339 
Pneumococcus  infection,  277,  462 
Pneumonia,  78 

aspiration,  283 

bronchial  breathing  in,  157 

broncho-,  274,  276,  277,  283 

catarrhal,  283 

central,  277 

characteristic  signs  of,  284 

chronic  interstitial,  84,  302 


INDEX 


509 


Pneumonia,  crepitant  rales,  in,  i6o 

croupous     (or    lobar),     277-283, 
302,  327 

distinguished  from  pleuritic  effu- 
sion, 282 

distinguished  from  tuberculosis, 
283 

fibrinous,  277 

hypertrophy  in,  198 

hypostatic,  337 

inhalation,  283 

leucocytosis  in,  449 

lobar,  277,  333 

lobular,  283 

massive,  277,  278 

nostrils  in,  18 

resolution  of,  281 

sputum  in,  304 

surgical,  278 

tuberculous,  295 

wandering,  281 
Pneumohydrothorax,  165 
Pneumopyothorax,  310 
Pneumoserothorax,  310 
Pneumothorax,  69,  82,  155,  298,  308 

closed,  311 

open,  311 
Poikilocytosis  in  blood  smears,  442 
Poisoning  by  gas,  coma  in,  485 

by  illuminating  gas,  breath  in,  22 

by  mercury,  gums  in,  25 

by  potassic  iodide,  gums  in,  25 

lead,  see  Plumbistn 

opium,  coma  in,  485 
Poliomyelitis,  (acute)  anterior,  38 

reaction  of  degeneration  in,  482 

atrophy  in,  39 

chronic,  hands  in,  51 
Polychromasia  in  blood  smears,  442 
Polynuclear  cells  in  blood,  443 
Polyuria,  394 
Portal  cirrhosis,  jaundice  in,  367 

obstruction,  causes  of,  365 

stasis,  ascites  in,  347 
Postepileptic  coma,  485 
Pott's  disease,  32,  34,  58-68,  461 
Precordial  region,  69 
Pregnancy,  chorieform  movements  in, 
47.  49,  50 


Pregnancy,  glucosuria  in,  401 

lordosis  in,  59 

spasm  in,  14 

tubal,  420 
Pressure,  253 

arterial,  102,  103,  107— 112 

blood-,  increased,  245 

arterial,    methods  of  measuring, 
107 

high  pulse,  225 

in  aneurism,  266 

in  pulmonary  artery,  237 

diastolic,  no,  112 

high  systolic  blood-,  1 1 1 

instruments  for  measuring,   107, 
108 

low  systolic  blood-,  112 

mediastinal,  299 

normal  blood-,  no 

systolic,  108,  109,  no 
Presystolic  murmur,  see  Murtnurs 
Procidentia,  419 

Progressive  muscular  atrophy,  fibril- 
lary twitchings  in,  475 

muscular    atrophy,    reaction    of 
degeneration  in,  481 
Prostate,    hypertrophy  of,    distended 

bladder  in,  411 
Prostatitis,   acute  retention   of  urine 

in,  412 
Pseudo-leukasmia,  tonsils  in,  28 
Psoas  abscess,  426 

spasm,  462 

spasm  of  hip,  458 
Psychic   functions,    examinations   of, 

483 
Ptosis,  16 

bismuth  X-ray  examination  in, 

358 
Pulmonary  abscess,  333 

disease,  mitral  stenosis  in,  217 
disease,  see  Lung 
hemotrhage,  285,  303,  304 
regurgitation,  247,  248 
oedema,  sputa  in,  303 
osteoarthropathy,  42,  44,  47 
stenosis,  see  Stenosis 
tuberculosis,  see  Tuberculosis  of 

lung 


510 


INDEX 


Pulmonary  tympanites,  300,  312 
Pulmonic  area,  167 

second  sound,  172,  174,  175,  198, 
204,  205,  238 

sound  in  mitral  stenosis,  213,  214 
Pulsation,  abnormal,  99,  263 

abnormal,  thoracic,  85 

capillary,  90,  220 — 221 

epigastric,  84,  198 

in  pleurisy,  86 

of  arteries,  88,  89 

presystolic,  87 

systolic,  220,  234 

systolic  venous,  87 

visible,  84,  197,  219, 
Pulse,  100 

anacrotic,  103 

bigeminal,  119,  215,  249 

bounding,  103 

capillary,  241 

compressibility  of,   102,  see  also 
Arterial  pressure 

Corrigan,  103,  221,  241,  230 

coupling  of,  215 

in  aortic  stenosis,  loi,  229 

in  misplaced  artery,  105 

in  mitral  regurgitation,  207 

in  mitral  stenosis,  213,  214 

irregular,  102,  116,  204 

method  of  feeling,  loi 

paradoxical,  249,  258,  260 

radial,  in  aneurism,  266 

rate,  loi,  102,  247 

rhythm  or  regularity,  102 

slow  (bradycardia),  15,  102 

tension,  103,  104,  106 

trigeminal,  249 

value  of,  100 

value  of  tracings,  113 

waterhammer,  221 

wave,  dicrotic,  103 

wave,  recording  of,  113 

wave,  size  and  shape  of,  102,  103 

see  also  Arrhythmia,  Arterywalls, 
Pressure,  arterial 
Pulsus  rarus,  parvus,  tardus,  229,  232 
Pupil,  15 

Argyll-Robertson,  16 

contraction  of,  16 


Pupil,  dilatation  of,  16 

reflexes,  15 

in  aneurism,  266 

irregularity  of,  16 

value  of,  in  diagnosis,  15 
Purpura,  nosebleed  in,  18 
Purulent   and  pleuritic   effusions, 

serous,  324 
Pus  in  feces,  380 

in  kidney,  396 

in  urine,  395,  405 

tube,  cause  of  peritonitis,  347 
Pyelitis,  urine  in,  409 
Pylephlebitis,  365 

Pylorus,  stenosis  of,  gastric  peristal- 
sis in,  351 
Pyonephrosis,  391 
Pyorrhoea  alveolaris,  25 
Pyuria,  395,  396 

vesical,  396 

Quinsy,  sore  throat,  28 

Rachitic  rosary,  65 
Rachitis,  58,  64 

arm  in,  42 

epiphyses  in,  42 

hair  in,  6 

head  in,  5 

splenic  enlargement  in,  387 

teeth  in,  22 
Radioscopy,  35,  61,  268,  287 

examination   in   spinal   tubercu- 
losis, 462 

examination    of     stomach,     bis- 
muth, 358 

in  aneurism,  271 

in  aortic  stenosis,  231 

in   bismuth   X-ray    examination 
of  stomach,  359 

in     diaphragmatic     movements, 

78,79 
in  interlobar  empyema,  325 
of  joints,  457 
Rales,   bubbling,    158,    159,    274,  276, 
336 
consonating,  288 
crackling,  159,  207,  277,  285,  286 
crepitant,  159,  160,  280 


INDEX 


511 


Rales,  moist,  208 

musical,  161 

palpable,  99 

squeaking,  153,  156,  274 

varieties  of,  158 
Raynaud's  disease,  55,  435,  483 
Reaction  of  degeneration,  481 
Recti,  separations  of,  342 
Rectocele,  419 
Rectum,  abscess  of,  414 

cancer  of,  414 

cancer  of,  stools  in,  379 

fissure  of,  414 

fistula  of,  414 

hemorrhoids  of,  414 

irritation    of,    in    intestinal    dis- 
ease, 374 

methods  of  examination,  413 

symptoms  which  suggest  exami- 
nation, 413 
Reflex  Achilles,  479 

Babinski,  480 
Reflexes,  477 

deep,  480 

of  pupil,  15,  477 

pharyngeal,  29 

pharyngeal,   in  postdiphtheritic 
neuritis,  29 

sexual,  481 

sphincteric,  481 

superficial,  480 

tendon,  477 
Regurgitation,  178,  179,  192 

aortic,  90,  178,  198,  218 — 226 

aortic  and  mitral,  241 

aortic,  capillary  pulsation  in,  220 

aortic,  causes  of,  218,  219 

aortic,  complications  in,  226 

aortic,  diagnosis  of,  225 

aortic,  diastolic  murmur  in,  223 

aortic,  Duroziez's  sign  in,  224 

aortic,  palpation  in,  221 

aortic,  physical  signs,  219 

aortic,  pulse  in,  221—222 

aortic,  with  stenosis,  242 

mitral,  201,  231,  239 

mitral,  diagnosis  of,  208 

mitral,  first  stage,  203 

mitral,  second  stage,  203 


Regurgitation,  mitral,  signs  of,  203 

mitral,  third  stage,  207 

mitral,  with  tricuspid  regurgita- 
tion, 235,  236 

pulmonary,  237,  238 

tricuspid,  208,  232-237 

tricuspid,  murmur  in,  233,  234 

tricuspid,  pulsation  in,  87,  234 

with  mitral  stenosis,  215 
Renal  calculus,  392,  397 

colic,  392 

disease,  diuresis  in,  i 

disease,  sweating  in,  i 

pyuria,  396 

suppuration,  396 

suppuration,  urine  in,  409 

tuberculosis,  397 

tumor,  397 

see  also  Kidney 
Resonance,  see  Percussion  resonance, 

hyper-,  297,  300,  330 
Respiration,  see  Breathing,  70 
Respiratory  movements,  261 
Retina,  17 

hemorrhage  of,  17 

see     also     Neuritis,     optic     and 
Atrophy,  optic 
Retraction  causes,  lung,  273 

of  thorax,  71,  72 
Retropharyngeal  abscess,  28 
Rheumatism,  acute  articular,  243,  259 
Rheumatoid  arthritis,  462,  464 
Rhythm,   disturbances  of,    213,   218, 
222,  245,  247 
gallop,  207,  245,  250 
modifications  in  cardiac,  175 
presystolic  gallop,  176 
protodiastolic  gallop,  176 
Rib,  cervical,  35,  39 
Rickets,  see  Rachitis 
Romberg's  sign,  476,  478 
Rosary,  rachitic,  65 
Rose  spots,  diagnosis  of,  339 
Round-worm  in  feces,  380 

Sacro-iliac  joint,  see  Hip-joint,  57 
Sahli's  test  for  haemoglobin,  437 
Salpingitis,  420 
Sansom's  sign,  267 


512 


INDEX 


Sarcoma,  glands  in,  3 1 

of  abdominal  wall,  343 

of  arm,  40 

of  kidney,  390 

of  legs,  43 1 

of  liver,  364 

of  lung,  oedema  of  arm  in,  40 

of  mediastinum,  334 

of  mediastinum,  oedema  of  arm 
in,  40 

of  scapula,  59 

of  testis,  417 

of  thigh,  426 

of  tonsil,  28 

toxemia  in,  449 
Scapula,  prominent,  59 

sarcoma  of,  59 
Scarlet  fever,  pharynx  in,  27 

fever,  tonsils  in,  27 
Scars,  92 

from     syphilitic    ulcers    on    leg, 

430 

of  forehead,  7 
Sciatica,  58 
Sclerosis,  multiple,    nystagmus  in,  16 

multiple,  paraplegia  in,  428 
Scoliosis  with  twisting  of  spine,  59 
Scrotum,  hernia  of,  417 

hydrocele  of,  417 
"Scurvy"  in  gums,  25 
Senility,  tremor  of  hands  in,  45 
Sensation,  delayed,  477 

disorders  of,  476 

dissociation  of,  476 
Sepsis,  leucocytosis  in,  449 

lymphocytosis  in,  450 

with  jaundice,  15 
Septicsemia  with  jaundice,  368 
Septum,  defects  in,  239,  251 
Serratus  paralysis,  scapula  in,  60 
Sexual  power,  481 
Sigmoid,  cancer  of,  377 
Situs  inversus,  83 
Skin  diseases,  chronic,  blood  in,  450 

in  jaundice,  368 

in  leprosy,  12 
•  in  myxcedema,  8 

in  phthisis,  12 

inspection  of,  90 


Skin,   lesions   of,   trophic,  in  atrophic 
arthritis,  466 

roughness  of,  100 

temperature  of,  100 

tumor  of,  343 
Skull,  enlargement  of,  5 
Sleep,  loss  of,  2 
Small-pox,  eruptions  on  forehead  in,  7 

throat  in,  27  ' 
Snuffles,  syphilitic,  18 
Sordes,  24 
Sound,  falling  drop,  165,  310 

lung-fistula,  166 

splashing,  310,  351 

succussion,  165 

systolic,  224 
Spade-hand,  51 
Spasm,  320 

cardio-,  353 

eclamptic,  106 

psoas,  57,  462 

psoas,  in  appendicitis,  376 

clonic,  475 

habit,  14,  47,  49 
Spasms,  in  chorea,  13 

in  hereditary  brain  defects,  14 

in  hysterical  conditions,  14 

in  torticollis,  33,  34 

laryngeal,  275 

muscular,  376,  459,  475 

of  bronchi,  300 

of  face,  causes  of,  13 

of  glottis,  76,  301 

of  hands,  47,  50 

of  hip,  458 

tonic,  475 

of  urethra,  412 
Speech,  loss  of,  482 
Sphincteric  reflexes,  481 
Sphygmograph,  113 
Sphygmomanometer,  1 1 1 
Spina  bifida,  60 
Spinal   column,    muscular   spasm   in, 

459 
cord,  paralysis  of  arms  in  diseases 

of,  39 
curvature,  34,  58,  59,  67 
curvature,  cardiac  impulse  in,  83 
myosis,  16 


INDEX 


513 


Spinal  column,  twisting,  68 
Spine,  chronic  diseases  of,  sphincteric 
reflexes  in,  481 

hypertrophic  arthritis,  467,  468, 
469 

tuberculosis  of,  58,  59 
Spirometer,  79 
Spitzenstoss,  81 
Spleen,  abscess  of,  348 

diseases  of,  63,  385 

enlarged,    distinguished   from 
tumors,  388 

enlarged,  types  of,  387,  388 

enlargement  of,  366,  385,  387 

palpation  of,  385 

percussion  of,  131,  386 

tumor  of,  343 
Splenic  anemia,  389 
Spondylitis  deformans,  467 
Sputa,  artificially  obtained,  287 

appearance  of,  303 

bloody,  303 

examination  of,  303—307 

staining  of,  305 

obtained  from  children,  303 

odor  of,  303 

origin  of,  303 

pneumonic,  304 

purulent,  302 

qualities  of,  304 

quantity  of,  303 
Squint,  16 
Starvation,  acetone  breath  in,  22 

intestinal  distention  in,  375 
Statistics  on  bladder,  410 

on    gall-bladder   and   bile-ducts, 
362^ 

on  diseases  of  the  intestine,  373 

on  diseases  of  liver,  361 

on  gastric  diseases,  360 

on  joint  lesions,  472 

on  kidney,  389 

on  pancreatic  disease,  372 

on  thigh  disease,  425 

on  thigh  tumors,  426 
Stenosis,  178 

aortic,    180,    226,    227.    232,    239 
271 

aortic,  inurinur  in,  228.  229 
33 


Stenosis,  aortic,  pulse  in,  229 
aortic,  thrill  in,  230 
mitral,  114,  180 
mitral  and  regurgitation,  240 
mitral,  As-Vs  interval  in,  213 
mitral,  auscultation  in,  212 
mitral,  cause  of,  209 
mitral,  diagnosis  of,  214-2 1 7 
mitral,    double    shock    sound  in, 

213.  215 
mitral,  embolism  in,  215 
mitral,  first  stage,  212 
mitral,  haemoptysis  in,  215 
mitral,  heart  beats  in,  213 
mitral,  in  women,  211 
mitral,  murmurs  in,  215,  216,  217 
mitral,  physical  signs  of,  211 
mitral,    pulmonic    second    sound 

in,  213 
mitral,  pulse  in,  213,  214 
mitral,  regurgitation  with,  215 
mitral,  second  stage,  213 
mitral,  third  stage,  2 14 
mitral,  thrombus  in,  215 
mitral,  uncompensated,  299 
of  a  bronchus,  274 
pulmonary,  231,232,  238,  250 
tricuspid,  237 

tricuspid,  after  pericarditis,  217 
tricuspid,  murmur  in,   215,   216, 
217 

Stethoscope,  in  heart  block,  115 
in  pneumonia,  281 
selection  of,  138  • 

use  of,  141-145 

Stokes-Adams  syndrome,  114,  248 
syndrome,  coma  in,  486 

Stomach,    bismuth    X-ray  examina- 
tion of,  358 
cancer  of,  360 
cancer  of,  glands  in,  3 1 
cancer  of,  statistics,  360 
contents,  acetic  acid  in,  356 
contents,  acidity  of,  356,  357 
contents,  blood  in,  356 
contents,  examination  of,  355 
contents,  fermentation  of,  361 
contents,  tree  hydrochloric  acid 
in,  tests  for,  357 


514 


INDEX 


Stomach,  contents,  in  achylia  gastrica, 
361 
contents,  in  hyperacidity,  361 
contents  in  stasis,  355,  358,  361 
contents,  lactic  acid  in,  357 
contents,  mucus  in,  356 
contents,  nitric  acid  in,  356 
dilatation  of,  361 
dilated,  351 

distention  of,  methods,  354,  355 
hyperacidity,  361 
hypoacidity,  361 
hypogastric  bulging  of,  351 
inspection  and  palpation,  350 
lavage  of,  355 

methods  of  examination,  350 
normal  outline  of,  359 
normal  splash  sound  in,  351 
position  of  normal,  354 
secretory   and   motor  power  of, 

351 

tube,  passing  of,  352 

ulcer  of,  statistics  of,  360 

visible  peristalsis  in,  351 

washing  of,  method,  354 

see  also  Gastric, 
Stomatitis,  breath  in,  22 

gangrenous,  26 

herpetic,  20 
Stools  in  gastric  ulcer,  360 

in  jaundice,  15,  366,  367 

in  pancreatic  disease,  371 
Strabismus,  16 

in  meningitis,  16 

in  syphilis,  16 

in  tumors,  16 
Streptococcus  infection,  tonsils  in,  27 
Strongyloides  intestinalis,  380 
Strychnine  poisoning,  spasm  in,  475 
Subphrenic  abscess,  348 
Subsultus  tendinum,  44 
Succussion,  165 
Sugar,  see  Glucosuria 
Sunstroke,  2,  485 
Suppurations,  chronic,  anemia  in,  447 

of  gums,  25 

renal,  396 
Sweating  in  jaundice,"'i5 

in  phthisis,  4 


Sweating,  night  and  day,  causes  of,  4 
Syncope,  244,  485 

local,  in  Raynaud's  disease,  56 
Syphilis,  breath  ia,  22 

chancre  of  penis  in,  415 

(congenital),  teeth  in,  22 

cornea  in,  16 

coryza  in,  18 

dactylitis  in,  55 

enlarged  glands  in,  93 

eruptions  on  forehead  in,  7 

glands  of  neck  in,  30 

hereditary,    delayed    closure     of 
fontanels  in,  6 

inguinal  glands  in,  424 

in  myocarditis,  244 

jaundice  in,  368 

keratitis  in,  16 

lip  chancre,  20 

lip  scars  in,  19 

loss  of  hair  in,  7 

mucous  patches  in,  19,  25 

nose  in,  18 

of  lung,  301 

orchitis  in,  416 

palate  in,  29 

ptosis  in,  16 

strabismus  in,  16 

teeth  in,  22 

tongue  in,  23 

ulcerations  of  tonsils  in,  27,  28 

Wassermann  reaction  in,  453 
Syphilitic  aortitis,  218 

liver,  364 

periostitis,  430 
Syringomyelia,  changes  of  nails  in,  51 

claw-hand  in,  51 

felons  in,  56 

Morton's  disease  in,  56 

with  atrophic  arthritis,  464 
Systole,  181 
Systolic,  murmur,  see  Murmttrs 

retraction,  220 

Tabes  dorsalis,  ataxia  in,  475 
dorsalis,  knee-jerk  in,  478 
dorsalis,  optic  atrophy  in,  17 
dorsalis,  paraesthesia  in,  477 
dorsalis  paraplegia  in,  428 


INDEX 


515 


Tabes  dorsalis,  reaction  of  pupil  in,  i6 
dorsalis,     Romberg's    sign,    476, 

478 
dorsalis,  sexual  power  in,  481 
dorsalis,    sphincteric  reflexes  in, 

4S1 
dorsalis,  ulcer  of  toe  in,  435 
dorsalis  with   atrophic   arthritis, 
464 

Tachycardia,  247 

paroxysmal,  116,  247 

Tactile  fremitus,  96,  258,  278,  291 
fremitus,  diminution  of,  98 
fremitus,  increase  of,  98 

Taenia  nana,  380,  383 
saginata,  380,  381 
solium,  380,  382 

Tallqvist's  test   for  haemoglobin,    19, 

437 
Tape-worm  in  feces,  380 
Teeth,  21 

carious,  25 

grinding  of,  22 

in  congenital  syphilis,  22 

in  cretinism,  22 

in  rickets,  22 

order  of  appearance,  21 

second,  21 
Temperature,  2 

in  hysterical  patients,  2 

in  osteomyelitis,  acute,  425 

method  of  taking,' 2 

significance  of,  2 

sub -normal,  3 
Tenderness  in  general  peritonitis,  347 

in  intestinal  diseases,  347 
Tenesmus  in  intestinal  disease,  374 
Tenosynovitis,  43 

of  Achilles  tendon,  433 
Tension  of  pulse,  103,  104 
Testes,  416 

absence  of  one  or  both,   418,  425 

cancer  of,  417 

haematocele  of,  417 

sarcoma  of,  417 
Tetany,  spasm  in,  50 
Thigh,  425 

cancer  of,  metastatic,  426 

diseases  of   statistics  on,  425 


Thigh,   intermittent   claudication    of, 
427 

meralgia,  paraesthesia  of,  427 

osteoma  or  exostosis,  of,  426 

sarcoma  of,  426 

tumors  of,  statistics,  426 
Thoma-Zeiss  blood  counter,  445 
Thoracic  aneurism,  see  Aneurism 

deformities,  64 

disease,  199—242 

disease,  methods  of  diagnosis  in, 
61—190 

pain  in,  156 
Thorax,  paralytic,  65 

tender  points  on,  99 
Thrill,  95,  251 

in  aortic  stenosis,  230 

in  cardiac  neurosis,  95 

in  mitral  stenosis,  216 

in  pulmonary  stenosis,  251 

presystolic,  95,  212,  213 

systolic,  207,  264 
Thrombosis,  215 

mesenteric,  349 

oedema  of  arm  in,  40 

venous,  36 

with  cervical  rib,  35 
Thrush,  27 
Thyroid  gland,  see  Glands 

tumor,  causes  of,  32 
Toes,  434 

lesions  of,  435 

perforating  ulcer  of,  43  5 

tender,   after  typhoid  fever,  436 
Tongue,  22 

cancer  of,  23 

coated,  23 

cyanosis  of,  23 

fissures  of,  24 

geographic,  24 

herpes  of,  23 

hypertrophy  of,  24 

in  bulbar  paralysis,  23 

in  constipation,  23 

in  cretinism,  24 

in  dementia  paralytica,  23 

indented,  23 

in  dyspepsia,  23 

in  facial  paralysis,  23 


516 


INDEX 


Tongue,  in  fever,  23 

in  gastric  fermentation,  23 

in  myxoedema,  24 

in  tuberculosis,  23 

in  typhoidal  states,  22 

jaundice  of,  23 

leukoplakia  buccalis,  24 

"simple  ulcers"  of,  24 

syphilis  of,  23,  24 

tremor  of,  22,  23 
Tonometer,  Gaertner's,  107 
Tonsillitis,  follicular,  27,  28 

follicular,  breath  in,  22 

glands  in,  30 
Tonsils,  26 

abscess  of,  28 

enlargement  of,  28 

examination  of,  27 

in  adenoids,  28 

in  diphtheria,  27 

inflammation  of,  27 

in  leukaemia  or  pseudo-leukemia, 
28,31 

in  pharyngitis,  27 

in  scarlet  fever,  28 

in  streptococcus  infection,  27 

malignant  disease  of,  28 

membrane  on,  27 

sarcoma  of  glands  in,  31 

swollen,  28 

ulcerations  of,  27,  28 

yellowish-white  spots  on,  27 
Topfer's  reagent,  357 
Tophi,  gouty,  diagnosis  of,  41,  42.  458, 

472 
Torticollis,  33,  34 

congenital,  33 

rheumatic,  34 

traumatic,  34 

with  spasm,  33,  34 
Toxemia,  cause  of  jaundice,  15 

fever  in,  2 

in  hepatic  cirrhosis,  2 

in  tuberculosis,  2 

in  typhoid,  2 

leucocytosis  in,  449 

lymphocytosis  in,  449 

shaking  head  in,  13 

tremor  of  hands  in,  45 


Tracheal  tug,  265 

Tracheitis,  274 

Traube's  semilunar  space,    131,   316, 

320,  345 
Trauma,  nosebleed  in,  18 
Traumatic  neuroses,  paralysis  in,  339 
Tremor,  475 
Tremors,  intention,  45 

of  hand  45 

of  hand  in  alcoholism,  45 

of  hand  in  cold,  45 

of  hand  in  fever,  45 

of  hand  in  Grave's  disease,  45 

of  hand  in  hysteria,  45 

of  hand  in  multiple  sclerosis,  45 

of  hand  in  nervousness,  45 

of  hand  in  old  age,  45 

of  hand  in  paralysis  agitans,  45 

of  hand  in  toxemia,  45 

of  tongue,  22 
Trichiniasis,  blood  in,  450 

oedema  of  lids  in,  14 

tenderness  of  leg  in,  433 
Trichuris  trichiura,  385 
Trichomonas  intestinalis,  380 
Tricuspid  stenosis,  see  Stenosis 

regurgitation,  see  Regurgitation 
Trigeminal  pulse,  249 
Trophic  disorders,  482 

disturbances,  54 
Trypanosomiasis,  blood  in,  455 
Tuberculin,  24,  41,  58 

injection,  285 
Tuberculosis,  106,  272,  303 

arthritis  in,  461 

dactylitis,  55 

emaciation  in,  2 

epididymitic,  416 

glandular,  30,  32 

in  ankle  bone,  434 

incipient,  285  ^ 

in  nose,  19 

of  bladder,  413 

of  bone  of  arm,  41 

of  joints,  461 

of  knee,  distinguished  from  sar- 
coma, 426 

of  lung,  275,   285-295,   308,    T,is, 
322 


INDEX 


517 


Tuberculosis  of  lung,  acute,  284,  295 
of  lung,  acute  miliary,  295 
of  lung,  advanced,  290 
of  lung,   cavity  formation,    292, 

333 
of  lung,  cog-wheel  breathing,  287 
of  lung,  cough  in,  285,  286 
of  lung,  examination  for,  286 
of  lung,  fever  in,  284 
of  lung,  hemorrhage  in,  285 
of  lung,  hoarseness  in,  285 
of  lung,  Litten's  sign  in,  286 
of  lung,     moderately    advanced, 

288 
of  lung,  percussion  in,  293 
of  lung,  rales  in,  286 
of  lung,  tuberculin  in,  286 
of  lung  with  emphysema,  294 
of  Kings,  see  also  Phthisis 
of  omentum,  351 
of  peritoneum,  34S 
of  sacro-iliac  joint,  57 
of  spine,  58,  59,  461 
of  spine,  lordosis  in,  59 
of  spine,  paraplegia  in,  428 
pharyngeal,  28 
renal,  397 
stiff  back  in,  57 
tongue  in,  23 
ulceration  of  tonsils  in,  28 
vertebral,  34 
vertebral,  abscess  in,  59 
Tug,  tracheal,  265 
Tumor,  abdominal,  343 

abdominal,     respiratory     move- 
ments of  belly  in,  339 
abdominal,  spine  in,  59 
alveolar,  25 
aneurismal,  82,  264 
below  diaphragm,  78,  82 
distinguished    from    enlarged 

spleen,  388 
epigastric,  350 
"epulis,"  25 
fluctuation  in,  99 
in  appendicitis,  376 
in  intestinal  obstruction,  377 
mediastinal,  36,  82 
motility  of,  343 


Tumor  of  arm,  40 

of  back,  59,  60 

of  bladder,  398 

of  chest,  70 

of  Hver,  343 

of  spleen,  343 

of  thigh,  426 

renal,  390,  397 
Tympanites,  pulmonary,  300 
Typhoid  fever,  breath  in,  22 

fever,  distinguished  from  malaria, 

449 
fever    distinguished    from    pyo- 
genic infections,  449 
fever,  hands  in,  44 
fever,  heart  sounds  in,  171 
fever,    intestinal    distention    in, 

374 
fever,  nosebleed  in,  18 
fever,  pulse  in,  221 
fever,  rose  spots  in,  339 
fever,    splenic    enlargement    in, 

387 
fever,  tender  toes  after,  436 
fever,  tongue  in,  22 
fever,  toxsemia  in,  2 
fever,  Widal  reaction  in,  452 

Ulcer,  duodenal,  360 

gastric,  360 

in  tuberculous  dactylitis,  55 

peptic,  360,  369 

peptic,  bismuth  X-ray  examina- 
tion in,  358 

perforating,  of  toe,  435 

"simple,"  of  tongue.  24 

of  tonsils,  27,28 
Uncinaria  americana,  382 
Uraemia,  aphasia  in,  482 

breath  in,  22 

distinguished  from  apoplexy,  484 
Urate   of  sodium  in   gouty  deposits, 

472 
Urethra,  abscess  of,  419 

caruncle  of,  419 

spasm  of,  412 
Urine,  acetone  in,  402 

albumin  in,  boiling  test,  399 

albumin  in,  Esbach's  test  for,  399 


518 


INDEX 


Urine,  albumin  in,  significance  of,  399 
albumin  in,  tests  for,  398 
albumin  in,  nitric  acid  tests    of, 

399 

albumose  in,  400 

alkaline,  398 

amount  of,  394 

animal  parasites  in,  407 

blood  in,  397 

casts  in,  403 

chemical  examination  of,  398 

diacetic  acid  in,  402 

examination  of,  393 

excessive,  394 

glucose,    fermentation    test    for, 
401 

glucose  in,  400 

glucose  in,  Fehling's  test  for,  400 

in  acute  nephritis,  408 

in  cystitis,  408 

in  jaundice,  15 

in  kidney  disease,  409 

litmus-test  of,  398 

optical  properties  of,  394 

overconcentration  of,  413 

pus  in,  395 

scanty,  394 

sediment  of,  395 

sediment  of,  crystals  in,  405 

sediment  of,  free  cells  in,  403 

sediment  of,  microscopic  exami- 
nation of,  403 

sediments,  significance  of,  395 

shreds  in,  395 

specific  gravity,  394 

spermatozoa  in,  405 

total  solids  in,  394 

turbidity  of,  395 
Uterus,  cancer  of,  420 

endometritis  of,  420 

erosions  of  cervix,  419 

fibro-myoma  of,  420 

laceration  of  cervix,  419 

malpositions  of,  419 

prolapse  of,  419 
Uvula,  29 

Valgus,  433 
Valve  areas,  62 


Valvular  heart  lesions,  191,  193,  245, 
246 

lesions,  combined,  239—242 
Varicocele,  417 
Varus,  433 
Vascular  phenomena,  86,  482 

phenomena    in     aortic     regurgi 
tation,  225 

tension,  104 
Vaso-motor  disorders,  482 
Veins,  abdominal,  88,  339 

inspection  of,  86 

pulsations  in,  see  Pulsation 

varicose,  430 
Venous  stasis,  195,  207 
A^entricle,  dilatation  of,  200 

hypertrophy   of,    197,    198,    202, 

233 
Vertebras,  cervical,  dislocation  of,  34 

deviations  of,  34 

when  palpable,  341 
Vocal  fremitus,    163,    258,    280,    291, 
321 

fremitus  in  pulmonary  tubercu 
losis,  285 

fremitus,  spoken,  164 
Voice  sounds,  see  Vocal  fremitus 
Vomiting,  face  after,  12 

in  appendicitis,  376 

in  gastric  cancer,  360 

in  gastric  ulcer,  360 

in  general  peritonitis,  347 

in  intestinal  obstruction,  377 
Vomitus,  "coffee-ground,"  360 
Vulva,  eczema  of,  418 

oedema  of,  418 

varicose  veins,  418 
Vulvo-vaginitis,  418 

Wassermann  reaction,  453 
Wasting    diseases,    depressed    fonta- 
nels in,  6 
Weeping  sinew,  43 
Weight,  gain  in,  i 

in  infectious  fevers,  2 

in  insomnia,  2 

in  malnutrition,  i,  2 

in  myxoedema,  i 

in  old  age,  i 


INDEX 


519 


Weight  in  toxaemic  states,  i 
loss  of,  I,  285,  368 
physiological  changes  in,  2 

Weil's  disease,  jaundice  in,  368 

Whooping-cough,  76 

lymphocytosis  in,  450 
oedema  of  lids  in,  14 

Widal     reaction,     interpretation 
452 
reaction,  technique  of,  452 


Winking  reflex,  481 

Wrist,  enlargement  of  bones  in  pul- 
monary  osteoarthropathy, 
42,  44,  53 
-drop,  in  lead  poisoning,  38 

Wry-neck,  33 

of,       X-RAY,  see  Radioscopy 

Yellow  fever  with  conjvmctivitis,  14 


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